KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

RECORDER GUIDELINES 2nd Edition

2017

KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

Recorder Guidelines

2nd Edition – 2017 KOMITE NASIONAL KESELAMATAN TRANSPORTASI

KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

Published separately in Bahasa Indonesia and English by: Komite Nasional Keselamatan Transportasi Jalan Medan MerdekaTimur Jakarta – Indonesia www.kemhubri.dephub.go.id/knkt

KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

RECORD OF REVISION

Revision No. Date of Revision Affected Pages Remarks/Purpose of Revisions Original 9 September 2014 All First Edition 1 14 September 2015 Foreword Person in charge changed Second Edition. Change KNKT Logo and revision to 0 14 August 2017 All several chapters to refer ICAO Annex 13 amendment 15

Note: Each amended page of KNKT guideline shall show the appropriate amendment number and date. A vertical black line on the right margin adjacent to the item that has been changed will indicate all changes. However, in any circumstances, the vertical black line is not necessary when the amendment is more than 50 percent of total pages, therefore new edition will be issued.

KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

FOREWORD

Komite Nasional Keselamatan Transportasi, KNKT (National Transportation Safety Committee, NTSC) is no blame, independent, multimode safety investigation body within the Republic of Indonesia responsible directly to the President of the Republic of Indonesia. KNKT has the main duty of conducts objective and independent transport safety investigation (investigation) for four modes of transportation which are; aviation, railway, road and marine transportation. KNKT investigation is intended to prevent similar occurrence in the future without implying blame or liability. KNKT investigation in aviation is to conduct objective and independent investigation of civil aircraft accident and serious incident under the provision of International Civil Aviation Organization (ICAO) Annex 13 and the Indonesian laws and regulations. This guideline contains policies and procedures related to the recorder data recovery and analysis in the aviation accident. The purposes of this guideline is as the fundamental principles in governing the investigation in a standardized basis to ensure that Aviation investigations are conducted in accordance with the correct application of Standard and Recommended Practices (SARP) for the provisions of ICAO Annex 13 as well as the Indonesian laws and regulations. Because of this guideline deals with both accident and serious incident investigations and, for reasons of brevity, the term “accident”, as used herein, applies equally to “serious incident”. Throughout this guideline, the use of the male gender should be understood to include male and female persons. This guideline will be amended periodically as new investigation techniques are developed and new information becomes available. Readers are invited to submit material for possible inclusion in subsequent editions of this guideline. This material should be addressed to: Komite Nasional Keselamatan Transportasi; Gedung Kementerian Perhubungan lantai 3, Jalan Medan Merdeka Timur Nomor 5, Jakarta – Indonesia 10110 or email to [email protected].

Jakarta, 14 August 2017

Dr. Ir. Soerjanto Tjahjono Chairman

KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

TABLE OF CONTENTS

TABLE OF CONTENTS ...... i TABLE OF FIGURES ...... iii GLOSSARY ...... iv LIST OF ACRONYMS ...... vii 1 GENERAL ...... 1-1 1.1 Background Legislations ...... 1-1 1.1.1 Indonesian Law number 1 of 2009 ...... 1-1 1.1.2 Civil Aviation Safety Regulation Part 830 ...... 1-2 1.2 Recorded Information ...... 1-2 1.3 Flight Recorder Specialist ...... 1-4 1.3.1 Recorder Specialist Duty and Responsibility ...... 1-4 1.3.2 Flight Recorder Specialist Recruitment ...... 1-5 1.3.3 Flight Recorder Specialist Training ...... 1-5 2 DATA DISCLOSURE AND ACCESS POLICY ...... 2-1 2.1 Data Disclosure and Access ...... 2-1 2.2 Data Disclosure Exceptions ...... 2-2 2.3 Storage and Handling of Recorded Information ...... 2-2 2.4 Other Investigations with KNKT Participation or Assistance ...... 2-2 2.5 KNKT Recorder Readout in Other State Facility ...... 2-3 3 RECORDER RECOVERY AND PREPARATION FOR DATA RETRIEVAL ...... 3-1 3.1 Recovery from Accident Site to the Laboratory ...... 3-1 3.1.1 Recovery by Non KNKT Personnel ...... 3-1 3.1.2 Recovery from Under Water ...... 3-3 3.2 Initial (Preparation) Phase ...... 3-3 4 RECORDER DATA RETRIEVAL AND PRESENTATION ...... 4-1 4.1 Data Recovery Process ...... 4-1 4.2 Initial Readout of a flight recorder ...... 4-1 4.2.1 FDR Data ...... 4-1 4.2.2 Animation ...... 4-2 4.3 CVR Data and Transcript ...... 4-2 4.4 Other Recorded Data ...... 4-2 4.5 The Recorder Report ...... 4-3

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KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

5 KNKT RECORDER LABORATORY ...... 5-1 5.1 FDR Data Recovery Capability ...... 5-1 5.2 CVR Data Recovery Capability ...... 5-1 6 APPENDIX: SAMPLE OF RECORDER REPORT ...... 6-1

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TABLE OF FIGURES

Figure 1: Sample of recorder ...... 3-2 Figure 2: Sample of deformation...... 3-2 Figure 3: Sample of recorder condition after post impact fire ...... 3-3

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GLOSSARY

When the following terms are used in this guideline, they have the following meanings: Accident: An occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down, in which: a) A person is fatally or seriously injured as a result of: 1) being in the aircraft, or 2) direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or 3) direct exposure to jet blast, except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew; or b) The aircraft sustains damage or structural failure which: 1) adversely affects the structural strength, performance or flight characteristics of the aircraft, and 2) would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to a single engine, (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes), or for minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike (including holes in the radome); or c) the aircraft is missing or is completely inaccessible. Note 1 – For statistical uniformity only, an injury resulting in death within thirty days of the date of the accident is classified as fatal injury Note 2 – An aircraft is considered to be missing when the official search has been terminated and the wreckage has not been located Note 3 – Guidance for the determination of aircraft damage can be found in KNKT Investigation Guideline. Accident investigation authority: The authority designated by a State as responsible for aircraft accident and incident investigations. Accredited representative: A person designated by a State, on the basis of his or her qualifications, for the purpose of participating in an investigation conducted by another State. Where the State has established an accident investigation authority, the designated accredited representative would normally be from that authority. Adviser: A person appointed by a State, on the basis of his or her qualifications, for the purpose of assisting its accredited representative in an investigation.

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Aircraft: Any machine that can derive support in the atmosphere from the reactions of the air other than the reactions of the air against the earth‟s surface. Contributing Factors: Actions, omissions, events, conditions, or a combination thereof, which, if eliminated, avoided or absent, would have reduced the probability of the accident or incident occurring, or mitigated the severity of the consequences of the accident or incident. The identification of contributing factors does not imply the assignment of fault or the determination of administrative, civil or criminal liability. Directorate General of Civil Aviation: The Indonesia governmental entity that are directly responsible for the regulation of all aspects of civil air transport, technical (i.e. air navigation and aviation safety) and economic (i.e. the commercial aspects of air transport). Flight recorder: Any type of recorder installed in the aircraft for the purpose of complementing accident/incident investigation. The flight recorder includes Automatic Deployable Flight Recorder (ADFR), a combination flight recorder installed on the aircraft which is capable of automatically deploying from the aircraft. Incident: An occurrence, other than an accident, associated with the operation of an aircraft which affects or could affect the safety of operation. Investigation: A process conducted for the purpose of accident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and/or contributing factors and, when appropriate, the making of safety recommendations. Investigator: A person on the basis of his or her qualification and competency to conduct transport safety investigation. In this guideline the Investigator mean KNKT investigator unless otherwise specified. Investigator-in-Charge: A person charged, on the basis of his or her qualifications, with the responsibility for the organization, conduct and control of an investigation. Komite Nasional Keselamatan Transportasi (KNKT): Indonesian accident investigation authority that is independent from State aviation authorities and other entities that could interfere with the conduct or objectivity of an investigation. Major Accident: An accident with potentially increases the complexity of investigation with regards to media interest or political issue, number institution involves, or status of occupants involves as crew or passengers. Maximum mass: Maximum certificated take-off mass. Operator: A person, organization or enterprise engaged in or offering to engage in an aircraft operation. Preliminary Report: The communication used for the prompt dissemination of data obtained during the early stages of the investigation. Safety action: any actions taken or planned to be taken at the time of completion of the final report following an accident to improve the condition by organization involve in an accident.

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Safety recommendation: A proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident. In addition to safety recommendations arising from accident and incident investigations, safety recommendations may result from diverse sources, including safety studies. Serious incident: An incident involving circumstances indicating that there was a high probability of an accident and associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down. Serious Injury: An injury which is sustained by a person in an accident and which: a. requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or b. results in a fracture of any bone (except simple fractures of fingers, toes or nose); or c. involves lacerations which cause severe haemorrhage, nerve, muscle or tendon damage; or d. involves injury to any internal organ; or e. involves second or third degree burns, or any burns affecting more than 5 per cent of the body surface; or f. involves verified exposure to infectious substances or injurious radiation. State of Design: The State having jurisdiction over the organization responsible for the type design. State of Manufacture: The State having jurisdiction over the organization responsible for the final assembly of the aircraft. State of Occurrence: The State in the territory of which an accident or incident occurs. State of the Operator: The State in which the operator‟s principal place of business is located or, if there is no such place of business, the operator‟s permanent residence. State of Registry: The State on whose register the aircraft is entered.

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KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

LIST OF ACRONYMS

The following abbreviations are used throughout this guideline: AAIF : Aircraft Accident Investigation Fundamental ACAS : Aircraft Collision Avoidance System ACCID : Accident ADREP : Accident/incident data reporting system AFCS : Automatic Flight Control System APU : Auxiliary Power Unit ATS : Air Traffic Service CASR : Civil Aviation Safety Regulation CVR : Cockpit Voice Recorder DAR : Direct Access Recorder (D) FDAU : (Digital) Flight Data Acquisition Unit DFRD : Digital Flight Data Recorder DGCA : Directorate General of Civil Aviation Doc. : Document DME : Distance Measuring Equipment ECCAIRS : European Co-ordination Centre for Aviation Incident Reporting Systems EFIS : Electronic Flight Instrument system FADEC : Full Authority Digital Electronic FDR : Flight Data Recorder HHMPI : Hand Held Multi-Purpose Interface ICAO : International Civil Aviation Organization IIC : Investigator-in-charge INCID : Incident KNKT (NTSC) : Komite Nasional Keselamatan Transportasi (National Transportation Safety Committee) MoU : Memorandum of Understanding NTSC : See KNKT OJT : On-the-job training PA : Passenger Address QAR : Quick Access Recorder SARPs : Standards and Recommended Practices SSFDR : Solid State Flight Data Recorder TAWS : Terrain Awareness Warning system

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UTC : Universal Time Coordinate

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1 GENERAL

1.1 Background Legislations

1.1.1 Indonesian Law number 1 of 2009 Pasal 357 Article 357, (1) Pemerintah melakukan investigasi (1) Indonesia government shall dan penyelidikan lanjutan mengenai institute an investigation to penyebab setiap Kecelakaan dan establish the cause of any civil kejadian serius pesawat udara sipil aircraft accident and serious yang terjadi di wilayah Republik incident occurs in the territory of Indonesia. the Republic of Indonesia. (2) Pelaksanaan investigasi dan (2) The investigation and follow-on penyelidikan lanjutan sebagaimana investigation as stated in (1) dimaksud pada ayat (1) dilakukan conducts by a national committee oleh komite nasional yang dibentuk that constitute and responsible to dan bertanggung jawab kepada the President. Presiden. Pasal 359 Article 359 (1) Hasil investigasi tidak dapat (1) The result of investigation shall digunakan sebagai alat bukti not be used as evidence during dalam proses peradilan. the court of law. (2) Hasil investigasi sebagaimana (2) The result of investigation as dimaksud pada ayat (1), yang stated in the point (1) which not bukan digolongkan sebagai classified as restricted informasi rahasia, dapat information, may be made public. diumumkan kepada masyarakat. Penjelasan pasal 359 Elucidations of article 359 Yang dimaksud dengan “informasi The items classified as restricted rahasia” (non disclosure of records), information (non-disclosure of records), antara lain: are as follows: a. Pernyataan dari orang-orang a. Statements of person taken during yang diperoleh dalam proses the investigation; investigasi; b. Rekaman atau transkrip b. Records and transcript of komunikasi antara orang-orang communication from persons involve yang terlibat di dalam in the aircraft operation; pengoperasioan pesawat udara; c. Medical and personal information of c. Informasi mengenai kesehatan persons involves in an accident or atau informasi pribadi dari orang- incident orang terlibat dalam kecelakaan

atau kejadian; d. Voice record in the cockpit (cockpit d. Rekaman suara di ruang kemudi voice recorder) and its transcript. (cockpit voice recorder) catatan kata demi kata (transkrip) dari rekaman tersebut;

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e. Rekaman dan transkrip dari e. Voice records and its transcript of pembicaraan petugas pelayanan communication personnel Air Traffic lalu lintas penerbangan (air traffic Services; and services); dan f. Pendapat yang disampaikan f. Opinion expressed in the analysis of dalam analisis informasi termasuk information including flight data rekaman informasi penerbangan recorder. (flight data recorder).

1.1.2 Civil Aviation Safety Regulation Part 830 830.14 Flight Recorder of Other State Investigation When an aircraft involved in an accident or a serious incident lands in Indonesia which Indonesia is not the State of Occurrence, the State of Registry or the State of the Operator, KNKT shall, on request from the State conducting the investigation, furnish the latter State with the flight recorder records and, if necessary, the associated flight recorders. 830.16 Investigator-in-Charge (IIC) b. The IIC have unhampered access to the wreckage and all relevant material, including flight recorders and Air Traffic Services (ATS) records, and have unrestricted control over it to ensure that a detailed examination can be made without delay by authorized personnel participating in the investigation. 1.2 Recorded Information The term “Flight Recorders” encompasses several types of recorders that can be installed on aircraft for the purpose of complementing accident investigation. The recorders on board on an aircraft requires crash survivable for the purposes of accident investigation which incorporate the functions commonly associated with a Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR). However, many aircraft also have other recorders which are not crash survivable that are used routinely for daily airline operations. These recorders can be very useful to investigators and will often survive a crash even though they are not crash-protected. Combination recorders, recorders which record multiple functions in the same unit, are also becoming increasingly common. Crash survivable recorders are designed to withstand high impact forces, short and long duration fires, penetration and other environmental conditions in order to maximize the potential of surviving an accident. Generally speaking, fire is the most common cause for the recording medium not to survive. These different types of recorders, both survivable and non-survivable, are referred to as „flight recorder‟ in a general sense but specifically they are: a. Flight Data Recorder (FDR) is a crash-survivable system for recording data parameters from the aircraft data systems. Parameters may be dedicated to the FDR but more commonly on newer aircraft, parameters are needed and used by the aircraft to operate and in these cases the data is readily available to be recorded by the FDR. Indonesia CASR describes the minimum number of parameters be recorded that are considered mandatory but most current aircraft

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manufactured record vast numbers of parameters on the FDR that often exceed the mandatory minimum number required. The term “FDR” (Flight Data Recorder) includes Digital Flight Data Recorder (DFDR), Solid-State Flight Data Recorder (SSFDR) and Universal Flight Data Recorder (UFDR). b. Cockpit Voice Recorder (CVR) is a crash-survivable system for recording the internal acoustic environment of the flight deck and internal cockpit crew conversation along with inter-aircraft radio communications through a Cockpit Area Microphone (CAM), boom microphones and Public Address (PA) system and radio-telephony communications. c. Data Link Recording is a crash-survivable recording which records digital messages transmitted between the aircraft and the ground. This method of communication replaces many of the traditional voice exchanges between an aircraft and air traffic control. Data link recordings are typically the same length of duration as the CVR. d. Combined Recorder, refers to a crash-survivable unit which records more than one function in one box. Typically, a combined recorder incorporates the FDR and CVR functions but can accommodate Image and Data link recording capabilities, as applicable. For redundancy, some large commercial aircrafts may have at least two boxes installed if a combined recorder is used. One may be located forward and one may be located aft. e. Quick Access Recorder/Digital Aircraft condition monitoring system Recorder (QAR/DAR) is a non-crash survivable system for recording data parameters that typically contains data for a longer duration than the FDR with either are movable memory unit for convenience of obtaining the flight data or a wireless download option. QAR and DAR may record the identical data stream as the FDR or, in some cases, receive different data streams that may capture additional parameters. It is important to obtain the data from the aircraft operator regarding the type and location of flight data and voice recorders. FDR, QAR and DAR frequently record voluminous information that, combined with the CVR, in many cases can provide essential information needed to thoroughly investigate an accident or incident. High priority must be given to their recovery from the wreckage and readout should take place as soon as possible. If the recorder is found to be damaged or requires special equipment for readout that is not available at the KNKT facility, then the Recorder Specialist shall make appropriate arrangements to access the recorded information. Specifications relating to the carriage of flight recorders on Indonesian registered aircraft are contained in CASR Part 121 and Part 135 accordingly. Devices that record flight event data include, but are not limited to Quick Access Recorder (QAR), flight test equipment, FADEC, PARs. Recorded information may be stored in „glass cockpit‟ instrument displays, Terrain Awareness Warning System (TAWS), Aircraft Collision Avoidance System (ACAS) equipment or in- flight tracking devices. These systems may be found in both small and large aircraft. Furthermore, any magnetic tape or digital memory chips found in the wreckage may contain flight data and shall be secured by KNKT investigator and treated as flight data recorder.

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Ground based recorded information is also extremely valuable resource for an investigation. Air Traffic Control communications and surveillance system recording, such as VHF radio communication and radar, can provide factual data when a crash protected flight recorder is not available. Also, many operators are now utilizing global positioning system based tracking equipment to follow the flight path of their aircraft. This information can be retrieved from ground based equipment and analyzed by Recorder Specialist to support an investigation. The laws and policies that govern the procedures regarding FDRs and recorded event data are generally applicable to any and all flight data that are recorded on board an aircraft. Any event data that are recovered from an aircraft following an accident are given the same protection and security of an FDR or FDR data. The protections pertaining to on-board recorders also apply to ground-based recorded flight data, for example Communication Navigation System/Air Traffic Management (CNS/ATM), Aeronautical Operational Control (AOC), Aircraft Communication Addressing and Reporting System (ACARS), etc. 1.3 Flight Recorder Specialist The Flight Recorder Specialist provides comprehensive technical support to the KNKT investigation team, by assisting in the recovery, analysis and presentation of data retrieves from a recorder. The main job of the Flight Recorder Specialist is to conduct flight recorder data download, processing and present reports in a clear and concise format to assist ongoing investigation analysis.

1.3.1 Recorder Specialist Duty and Responsibility a. Provide comprehensive technical support to KNKT recorder team. b. Preparing equipment (hardware and software) and procedure, to allow the efficient and accurate recovery, analysis and presentation of recorder data. c. Liaise with internal staff and external stakeholder and service provider, to maintain and ensure the continued and efficient operation of dedicated data recovery and analysis equipment. d. Succinctly and clearly communicate the result of data analysis to investigation team member, and under special conditions, to external stakeholders. e. Develop objectives and plan short-term task, and provide input to the planning of long-term initiatives for KNKT recorder facility. f. Carry out specific recorder data recovery, analysis and presentation tasks under the general direction of the Chief of Recorder Laboratory, in both laboratory and on-site environments. g. Actively contribute to, and promote the KNKT collegiate culture and its promotion of transport safety awareness. h. Maintain the confidentiality of the information retrieved from the recorder according to the Indonesian Law number 1 of 2009 and the KNKT Policy and Procedures.

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1.3.2 Flight Recorder Specialist Recruitment The successful candidate for this position will be able to satisfy the following key criteria: a. Qualification and Technical Skills 1) Holds an applied science or engineer qualification in audio, digital electronics, electrical system, computer system, avionic or related field with minimum experience of 2 years on the specific field. 2) A fundamental understanding of the technologies employed in the acquisition and storage of engineering data relating to the operation of transport vehicle and/or mechanical equipment. 3) A good general knowledge of data communications and interface technologies. 4) Demonstrated ability to rapidly learn and use computer-base software and system for the analysis, interpretation and presentation of engineering data. b. Safety Awareness 1) Evidence of an ongoing interest in the transport industries and an awareness of current safety issues relevant to the industries. 2) Broad general knowledge of the function and role of KNKT. c. Analytical, communication and technical writing skill 1) Demonstrated analytical, research and problem-solving skills. 2) Evidence of a developing capacity for compiling concise, logical and technically correct written output using Microsoft Office applications. 3) Demonstrated verbal communication and presentation skill, preferred in English, with experience working in a team-based structure to achieve defined goals. d. Personality 1) Personal drive and integrity of the highest order. 2) An appreciation of small team dynamics and methods for fostering effective teamwork. 3) Personal responsibility for achieving agreed objectives and progressing work tasks. 4) A strong commitment to learn and professional development.

1.3.3 Flight Recorder Specialist Training Several trainings courses including on the job training will be provided to candidate who has been selected to be recorder specialist: a. General Investigation Training 1) Aviation knowledge (for candidate from non-aviation background); 2) Aircraft Accident Investigation Fundamental (AAIF); 3) Blood borne pathogen; 4) KNKT Policy and Procedures; 5) Human Factors for Investigation 6) Analysis Training.

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b. Specific Recorder Training 1) Introduction to Flight Recorder a) To familiarize with historical flight recorder development, types of recorders and how to obtain recorder. b) To know about ARINC specs 542/573/717/747/429 for recorders. 2) Download of FDRs To know how to download FDR using any of kind OEM (Original Equipment Manufacturer) equipment. 3) Recorder Evidence Tracking To be able to track and document the condition and operations performed on a flight recorder examined as part of air safety investigation 4) Recorder Fleet To ascertain aircraft type, recorders, acquisition units and frame formats currently used in the Indonesian fleet 5) Analysis FDR Software a) To introduce the concepts, module, structure and file format b) To utilize the software including importing, exporting and manipulate flight data to be used in an investigation c) To use FDR files for investigations 6) Download of CVRs How to download using any of kind OEM equipment 7) Analysis CVR Software a) To be able to import CVR files into audio software and apply basic enhancements b) To synchronize audio files with FDR files c) To create an audio file to be utilize by investigator d) To be able to transcript audio e) To provide an audio file and transcript of the audio than can be utilize by the investigator 8) Animation Software a) To be able to utilize and understand the limitation of animation software to present flight data b) To demonstrate the production of an aircraft flight path using FDR data and create an animation containing 3-D aircraft and instruments 9) Combined Analysis with Other Software for Presentation a) To use analysis software in other software for better presentation b) To utilize analysis software to export and then manipulate flight data in other presentation software 10) Recorder Report Writing To made recorder report summary of an investigation c. On the job training On the job training is provided to a candidate to ensure the ability to perform the duty as Recorder Specialist. The Chief of Recorder Laboratory will supervise the OJT.

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2 DATA DISCLOSURE AND ACCESS POLICY

2.1 Data Disclosure and Access Flight recorders may contain highly sensitive material. The Indonesian Law number 1 of 2009 prohibits disclosure of the information. It is KNKT policy, apart from publishing relevant information in the investigation report, is to disclose information contain in the flight recorders only to parties participating in the KNKT investigation. Recorders data are classified as non-disclosure information according to the Indonesia Aviation Act number 1 of 2009. The data shall not be disclosed for other purpose than safety investigation. FDR parameter conversion information may be proprietary, should release to the parties be needed then written acknowledgement of responsibility is required (see Investigation Guidelines). The Chairman, the Head of Aviation Accident Investigation Sub Committee, IIC, Chief of Recorder Laboratory and the assigned Recorder Specialist are the only personnel automatically authorized access to the recorder data. The Recorder Specialist assigned to the accident investigation has complete access to the recorder and data at all times. Additionally, any Recorder Specialist may assist with the recovery and analysis of recorded data when necessary. The use of additional resources must be approved by the Chief of Recorder Laboratory. Sensitive information shall only be provided to participated investigators when required to perform their duties, „need to know‟ basis. Access to the sensitive information shall be logged by the Recorder Specialist. The permission of the Chairman is required before disclosing recorded data to Accredited Representatives or participants of investigation from other States, regulator or a related operator. Disclosure may be considered necessary for the purpose of enhancing safety by identifying a safety hazard in timely manner and determining appropriate safety actions. The Recorder Specialist shall keep the IIC apprised of information and activities concerning the flight recorder or recovered data. In particular, any observations that may be significant to the investigation shall be brought to the IIC attention. Preliminary set of plots and tabular data shall (hardcopy or electronically) be sent to the IIC, who coordinates distribution to the party members, as necessary. Updates and corrections to the preliminary data (plots and corresponding tabular data) shall be provided to the IIC during the course of the investigation, the revision number and date of the plots and tabular data will be identified. The IIC shall coordinate the distribution of recorder information to parties on accident site. The distribution of recorder information or electronic file of the recorder data shall be limited to the KNKT investigation team and accredited representatives. An Expert or an Observer is not permitted to have copy of the recorded data. Animations, reconstructions or graphic simulations are not typically released with FDR data, unless authorized by the Chairman, the Head of Aviation Accident Investigation Sub Committee or the IIC, in consultation with the Chief of Recorder Laboratory.

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KOMITE NASIONAL KESELAMATAN TRANSPORTASI RECORDER GUIDELINES

The Final Report shall contain finalized and validated data for the parameters and time periods used and deemed pertinent, but not necessarily for every parameter and data point recorded. Copies of the waveform or binary data are generally not released, unless necessary for the investigation analysis and authorized by the Chairman, the Head of Aviation Accident Investigation Sub Committee or the IIC, in consultation with the Chief of Recorder Laboratory. 2.2 Data Disclosure Exceptions In any stage of the investigation process, when an unlawful interference become known or suspected, KNKT shall immediately initiate action to ensure that the Civil Servant Investigators are so informed. If the information of known or suspected unlawful interference is identified from the flight recorders, the Recorder Specialist shall notify the IIC, Head of Aviation Accident Investigation Sub Committee and the Chairman. In this case, KNKT will seek necessary coordination with the judicial authorities. KNKT may also provide the flight recorder information as requested by the Civil Servant Investigator. The release of flight recorder information to the Civil Servant Investigator shall be approved by the Chairman.

2.3 Storage and Handling of Recorded Information The KNKT Laboratory Facility is provided with electrical lock and only Chief of Recorder Laboratory and Recorder Specialist have access. Any person, other than the Chief of Laboratory Recorder and the Recorder Specialist, when enters the recorder laboratory shall not carry any recording equipment such as video or camera, mobile phone or voice recorder. All data readout from the recorders shall be stored in the recorder laboratory. The recorder data that is ready for analysis by investigation team may be stored in the KNKT server database provided with special password to access the data. 2.4 Other Investigations with KNKT Participation or Assistance Under ICAO Annex 13, the KNKT may be asked to participate or assist in other State investigation. The KNKT may also assist other organization including military investigation. The KNKT assistance may include the resources of the recorder laboratory. The Chairman shall appoint Accredited Representative to assist the other State investigation and liaison to assist other organization investigation. The KNKT Accredited Representative or KNKT liaison shall coordinate the scope of the requested services through the Chairman or the Head of the Aviation Accident Investigation Sub Committee. The Chief of Recorder Laboratory shall select a date for recorder services at KNKT office to conduct such assistance. Participants from the organization conducting investigation and their technical advisors shall clearly be identified to the Recorder Specialist to avoid unauthorized access to the recorder data.

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The Recorder Specialist shall keep the KNKT Accredited Representative or liaison and organization conducting investigation representative apprised of any recorder activities or actions. When provide assistance, the Recorder Specialist shall advise the representative of the organization conducting the investigation of the KNKT recorder policies and procedures. In the absence of specific guidance from the organization conducting the investigation, pertinent KNKT recorder policy, standard practices and procedures apply. Any issues or conflicts concerning recorder procedures, the procedure of the organization conducting the investigation shall be followed as much as possible or alternative procedures agreed by both parties. Agreed procedures should be documented and copies provided to both parties before work begins. Generally, the organization conducting the investigation may require a brief report of procedures performed, along with plots, if applicable. At the request of the organization conducting the investigation representative, the data, plots and reports shall be distributed, in consultation with the KNKT Accredited Representative or liaison. The original data and the recorder shall be returned to the organization conducting the investigation representative. After completion of the KNKT assistance to the other organization investigation, the flight recorder data shall be submitted to the other organization representative and the data in KNKT shall be erased. 2.5 KNKT Recorder Readout in Other State Facility In some cases, the recorder laboratory may be unable to download the recorder data due to the damage to the recorder or the recorder is a unique type. If recorder laboratory is unable to download the recorder data, the Chief of Recorder Laboratory shall notify the Head of Aviation Accident Investigation Sub Committee and the IIC. Where possible, the Chief of Recorder Laboratory should suggest what facilities may be available to assist with the recorder data recovery. The Head of Aviation Accident Investigation Sub Committee or the IIC will select another State facility based on the following criteria: a. The possibility of the real or perceived conflict of interest; b. The availability of an MoU between KNKT and the State; c. The suitability to transport the recorder; d. Distance from Indonesia; e. Resources that may arise for the downloading process. The Chief of Recorder Laboratory will coordinate with the other State recorder specialist and provide recorder details and scope of work.

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3 RECORDER RECOVERY AND PREPARATION FOR DATA RETRIEVAL

3.1 Recovery from Accident Site to the Laboratory Flight recorders, and other recording devices, may contain significant data that is essential to an investigation. The recorders should be recovered as soon as possible and taken to the recorders laboratory for readout. The data contained in the recorder may assist the investigation process on site. Upon received notification of an accident involving an aircraft where a flight recorder is required to be installed, the IIC considers whether the FDR might contain information relevant to the investigation (taking into consideration that the FDR can record a minimum of 25 hours of flight information and a CVR may contain 30 minutes or 120 minutes of operation). Consultation with the Chief of Recorder Laboratory of may be necessary to determine the relevance of recorded information. It is important to obtain the data from the aircraft operator regarding the type and location of flight data and voice recorders. The Recorder Specialist shall prepare the facility as soon as this information arrives in recorder laboratory . When a recorder has been recovered from an accident site, the part number, serial number and physical condition of the recorder shall be reported to the Recorder Specialist. If there is any visible damage as result of impact or fire, a picture of the recorder should be send to the Recorder Specialist. The recorder unit shall not be tampered with or opened, and the recording medium shall not be removed (i.e., the tape or memory module) until the recorder reaches the recorder laboratory . The Recorder Specialist, based on the initial data, shall prepare the recorder laboratory for readout. Should the recorder laboratory is unable to download the data, facility of another State shall be chosen and contacted. The selection of other State facility is described in the Subchapter 2.5 of this guideline. The recorders shall be shipped to the recorder laboratory in a manner that protects it from damage (i.e., inside a cardboard or wooden box, wrapped in either foam or bubble-wrap or in a container filled with foam peanuts). When the recorders are recovered from under water, the recorders shall be rinsed in fresh water and shall remain immersed in freshwater and transported to the KNKT facilities. Transport may require the recorder to be shipped in a water proof container. During the shipping, the recorders shall not be scanned in security facility (x-ray scanner) since it may endanger the data stored. The assigned investigator will be provided with special letter to get clearance from the security for the recorder not to be scanned.

3.1.1 Recovery by Non KNKT Personnel In an extreme accident site or when recorders are suspected under water and the investigator is unable to reach the site, it may require other personnel such as search and rescue or military personnel to recover the recorders. Prior to assign personnel to recover the recorders, a briefing shall be performed. The briefing should include the following: a. The pictures of a recorders (if possible an example of the recorder expected to

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be recovered) including the possibility of deformation; b. Location of the recorder in the aircraft and possible location after accident; c. How to take out from the original position; d. How to handle until it delivered to investigator.

Figure 1: Sample of recorder

Figure 2: Sample of deformation.

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Figure 3: Sample of recorder condition after post impact fire

3.1.2 Recovery from Under Water If recorder is recovered in water, it shall not be allowed to dry out to prevent corrosion. When recovered from sea water, it is recommended to wash it with fresh water and immediately be packed in fresh water (if possible). The packing may require a water proof container. Containers may be obtained from recorder laboratory or purchased locally. Packaging may also be accomplished by sealing the recorder (in water) inside a plastic beverage container with silicon adhesive or a similar sealant. The investigator may contact the Chief of Recorder Laboratory and the Recorder Specialist for further assistance. 3.2 Initial (Preparation) Phase Recorder information shall be informed to the Chief of Recorder Laboratory and the Recorder Specialist, as soon as possible. This information can be obtained from the airline and/or the airframe manufacturer. Specifically, the following information is required to facilitate data readout: a. FDR manufacturer/model (Fairchild, Sundstrand, Allied Signal, L3, etc.); b. FDR Part number and Serial Number; c. FDAU (Flight Data Acquisition Unit) manufacturer/model and part number; d. Parameters recorded; e. Word(s) and bit location(s) of each parameter; f. Conversion algorithm for each parameter; g. Parameter range; h. Original owner/upgraded retrofit history; i. Airline, recorder maintenance/readout facility contact phone number. Preliminary accident information shall be informed to the Chief of Recorder Laboratory or the Recorder Specialist, as soon as possible. Specifically, the

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following information is required to facilitate data readout: a. Event description (phase of flight, type of event); b. Aircraft type; c. Flight number; d. Flight itinerary; e. Number of flights after event, if the recorder is not removed immediately; f. Local altimeter setting at the time of the accident/incident; g. Elevation of accident/incident site; h. Location of previous takeoff, runway used, and field elevation; i. Local altimeter setting at time of takeoff; j. Time of departure, coordinated universal time (UTC); k. Time of accident/incident (UTC); l. Accident site conditions that may have cause damage to the recorder (fire duration, fuel type, etc.).

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4 RECORDER DATA RETRIEVAL AND PRESENTATION

4.1 Data Recovery Process Upon receives recorder from the accident site to recorder laboratory, the Chief of Recorder Laboratory or the Recorder Specialist handles and secures the recorder and its original recording medium. The condition of the recorder upon received shall be documented. If the recorder is damaged, the damage shall be documented. The Recorder Specialist downloads the original tape or memory from the flight recorder. The data is transferred or downloaded from the original medium and are digitally stored. The Recorder Specialist performs an initial check of the readout to determine that information relevant to the investigation has been recorded and analyzed. 4.2 Initial Readout of a flight recorder After receiving the recorder, the Recorder Specialist or the Chief of Recorder Laboratory shall photograph and document the condition of the recorder. This is required to identify the recorder received and to make an assessment of the condition of the recorder should any special data recovery techniques be required. The Recorder Specialist will perform the initial download. If the download is successful, the recovered data will be examined and an initial assessment will be made. The Recorder Specialist will confirm that information relevant to the investigation has been captured by the recording. If the download is not successful the Recorder Specialist will assess the recorder status, develop and implement a plan to recover the stored data. Any critical information that might assist in the field phase of the investigation should be relayed to the IIC in a timely manner. The IIC or an investigator assigned by the IIC may request special parameter to be analyzed for the purpose of assisting the field investigation. In any circumstance that the Recorder Specialist requires to brief the IIC regarding the recorder data, the conversation shall be made considering that the information is classified as restricted information. When briefing is conducted via telephone, the conversation shall be conducted in secure area to avoid the information be aware to unauthorized person. An electronic file containing preliminary plots and data may be sent to the IIC and the investigator, in consultation with the Chief of Recorder Laboratory.

4.2.1 FDR Data The FDR data may be presented by the Chief of Recorder Laboratory or Recorder Specialist in a tabular and/or graphical format to enable analysis of the information. Graphical presentation of the validated information may be included in the investigation report. Parameter to be included in the graph varies depend on the type of occurrence. The IIC or investigator team may request certain parameter to be included.

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4.2.2 Animation Recorder laboratory is capable to create animation based on the FDR data. The animation may also include voice from the CVR or ATC communication record. An animation is created to assist with investigation analysis. Animations are complex to create and require considerable resources, therefore an animation will only be created when the Head of the Aviation Accident Investigation Sub Committee or the IIC consider it is needed to fully understand the accident sequence. The animation may be replayed to the investigation team members for analysis. The animation replay shall be performed in the recorder laboratory. The animation may also be shown to the involved parties for the purpose of hazard identification. Limited personnel are allowed during the animation replay. No mobile phone, camera, voice or video recorder is permitted in the recorder laboratory during the animation replay. The reproduction of animations (video) for other than investigative use shall be coordinated and approved through the Chairman and the animation source files shall not be released.

4.3 CVR Data and Transcript The transcript of the CVR voice data shall be made as soon as possible. Any significant information shall be forwarded to the IIC to assist the investigation. The CVR transcript shall include time (in hour, minute and second), the source of the voice, note of the voice and remark. The investigator with pilot or ATC background may assist during the transcription process. For the purpose of investigation report, the general context of the conversation may be included to enhance the understanding of the accident sequence.

4.4 Other Recorded Data The Air Traffic Control (ATC) may have recorded information that may include communication and aircraft surveillance information. The recorded information is stored at the ATC facilities, normally for a nominal period of 30 days. The ATC recording can provide an insight into the performance of the ATC system in the accident. The ATC information may be the only source of recorded information for an aircraft without flight recorder. The Closed-Circuit Television (CCTV) may record significant information of the accident. This recorded data may be useful to be collected by the investigator during the investigation. The Airborne Collision Avoidance System (ACAS) and Terrain Avoidance Warning System (TAWS) fitted to an aircraft provide a warning to flight crew of an aircraft hazardous proximity to another aircraft or terrain. The warning systems are also fitted with a logging function that can store snapshots of aircraft operation. Some aircraft are fitted with engine health monitoring systems, or Engine Condition Trend Monitoring (ECTM) data loggers. These systems record engine operating information and, in some cases, aircraft flight path parameters. Aircraft tracking systems, such as „Bluesky‟ and „Skynet‟ may be adopted by aircraft

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operators. The tracking systems are capable of logging aircraft position and altitude which can be used to generate aircraft flight profiles. The Recorder Specialist are able assist the investigation by analyzing and combining the FDR and/or CVR information with other recorded information that may be available.

4.5 The Recorder Report The recorder report typically contains information about the information of the recorder type, the condition of the recorded (with appropriate documentation), data extraction methods, quality and summary of events. The recorder report is made by the Recorder Specialist. The Chief of Recorder Laboratory shall review and approve the recorder report.

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5 KNKT RECORDER LABORATORY

5.1 FDR Data Recovery Capability The Recorder Laboratory is capable to download the data of several manufacturers FDR such as Fairchild, Sundstrand, Allied Signal, L3, and Honeywell. The Recorder Laboratory for FDR data recovery is equipped with the following special tools: a. Flight Data Systems - Hand Held Multi-Purpose Interface (HHMPI); b. L-3 Aviation Recorders - Portable Interface; c. Avionica - Ruggedised Support Unit (RSU II); d. Manufacturer specific “Golden chassis” flight recorder. The Recorder Laboratory for FDR data recovery utilizes the following special software: a. Canadian Aviation Electronics Flightscape - data recovery and analysis tools; b. Flight Data Company - Ground Replay and Analysis Facility (GRAF) data analysis tool.

5.2 CVR Data Recovery Capability The Recorder Laboratory for CVR data recovery is equipped with sound proof room and audio recording and replay equipment. Four speakers are available to represent four channels of CVR during the replay. The Recorder Laboratory for CVR data recovery utilizes the following special tools: a. Flight Data Systems - Hand Held Multi-Purpose Interface (HHMPI) b. L-3 Aviation Recorders - Portable Interface c. Fairchild hardware interface for tape based CVR d. Honeywell hardware interface for tape based CVR The Recorder Laboratory for CVR data recovery utilizes several audio software tools for CVR replay and analysis as follows: a. AVID - Pro Tools b. Sony - Sound Forge c. Adobe - Audition No mobile phones are allowed to be active in the recorder laboratory when CVR data downloading process to avoid electromagnetic interference.

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6 APPENDIX: SAMPLE OF RECORDER REPORT Recorder Laboratory Report KNKT.16.05.11.05

KOMITE

NASIONAL

KESELAMATAN

TRANSPORTASI Investigation Note on Flight Data Recorder Readout and Analysis

In Flight Turbulence Airbus 330-243, A6-EYN Near Pangkal Pinang – Bangka Island Republic of Indonesia

4 May 2016

KOMITE NASIONAL KESELAMATAN TRANSPORTASI

REPUBLIC OF INDONESIA

2016

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CONTENTS

DOCUMENT RETRIEVAL INFORMATION ...... Error! Bookmark not defined. Factual Information...... Error! Bookmark not defined. Flight Data Recorder (FDR) ...... 6-5 Cockpit Voice Recorder (CVR) ...... 6-7 Sequence of events from Recorders ...... 6-9 Flight Path ...... 6-12 ATTACHMENTS ...... Error! Bookmark not defined. CVR Transcript ...... Error! Bookmark not defined. Plots Error! Bookmark not defined. Sequence of Events Table ...... Error! Bookmark not defined. Google Earth ...... Error! Bookmark not defined. List of FDR Parameters ...... Error! Bookmark not defined.

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DOCUMENT RETRIEVAL INFORMATION

Report No Publication date No. of pages

KNKT.16.05.11.05 August 2016 13

Publication title

In Flight Turbulence, Airbus 330-243 (A6-EYN), Near Pangkal Pinang – Bangka Island, Republic of Indonesia, 4 May 2016

Analysed by

NTSC Flight Recorder Laboratory Team

Prepared by

Komite Nasional Keselamatan Transportasi Recorder Laboratory

Ministry of Transportation

Jl. Medan Merdeka Timur No. 5 Jakarta 10110 knkt.dephub.go.id/knkt

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FACTUAL INFORMATION

Occurrence Summary

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Flight Data Recorder (FDR)

Manufacturer L3-Comm Model FA2100 Part Number 2100-4045-00 Serial Number 000643370 Date received 5-May-2016 Date downloaded 6-May-2016 Equipment used FDS HHMPI Did memory module required to be No mounted on a donor chassis? File name A6-EYN_06052016_0031.FDR File size 98.3 MB Duration of recording (hours) 333.2 Contained occurrence Yes Number of previous flights 38 (including serious incident) Time/ Date of first flight on FDR 11:22:14 UTC 15Apr 2016 Data frame -- Frame format descriptor (FFD) A332-A333_256_TD-005-804_rev.ffd Parameters 1172

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Figure 1: A6-EYN FDR

Figure 2: A6-EYN FDR Dataplate

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Cockpit Voice Recorder (CVR)

Manufacturer L3-Comm Model FA2100 Part Number 2100-1020-02 Serial Number 000113730 Date received 5-May-2016 Date downloaded 6-May-2016 Equipment used Honeywell PATS Did memory module required to be No mounted on a donor chassis? File name A6-EYN.CVR File size 109 MB Duration of recording (hours) 2.0 Contained occurrence Yes Channels No Source Length 1 Public Address (PA) 124.2 mins 2 Co-pilot 124.2 mins 3 Pilot 124.2 mins 4 Cockpit Area Microphone 124.2mins (CAM)

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Figure 3: A6-EYN CVR

Figure 4: A6-EYN CVR Data plate

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Sequence of events from Recorders  Plots, sequence of events table from FDR and CVR (see attachments)

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Figure 5: Plot Graphic FDR of A6-EYN incident flight

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Figure 6: Plot Graphic FDR of A6-EYN incident flight zoom

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Flight Path Figure 7: Google Earth image of A6-EYN from DXB to CGK flight path

Figure 8: Google Earth image of A6-EYN turbulence flight path

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Figure 9: Google Earth image of A6-EYN turbulence position zoom

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ATTACHMENTS

CVR Transcript

Draft_Transcript_A6-EYN.xlsx

Plots

A6-EYN_Turbulence_Rev-1.jpg

A6-EYN_Turbulence_(ZOOM).jpg

Sequence of Events Table

A6-EYN_Turbulence_Rev-1.xls

Google Earth

A6-EYN_Turbulence_Point_and_44_sec.kml

List of FDR Parameters

A6-EYN_parameters_list.xlsx

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KOMITE NASIONAL KESELAMATAN TRANSPORTASI Jl. Medan Merdeka Timur No.5 Jakarta 10110 INDONESIA

Phone: +62 nd21 351 7606 / 384 7601 Fax: +62 21 351 7606 Call Center: +62 812 12 655 155 2 Website:Edition knkt.dephub.go.id/knktRevision: Email: 0 [email protected]: - 6-15 - This document is uncontrolled if printed, please verify that it is the latest copy, see online version