Indonesian BAe146 crash

[captainspeaking]

Aviastar Mandiri in Indonesia lost their BAe 146-300 today. The aircraft reportedly crashed into a mountain on its way to pick up the governor of Papua. This is their second accident

Aircraft Accidents 2009 (http://www.airlineupdate.com/airlines/airline_extra/accidents/year_index/accidents_2009.htm)

[akerosid]

According to Flight, this was E-3189, formerly G-JEBC of Flybe:

No survivors as Aviastar 146-300 crashes in Indonesia (http://www.flightglobal.com/articles/2009/04/09/325007/no-survivors-as-aviastar-146-300-crashes-in-indonesia.html)

JetPhotos.Net Photo » G-JEBC (CN: E3189) Flybe British Aerospace BAe 146-300 by John Fitzpatrick (http://jetphotos.net/viewphoto.php?id=5743872&nseq=14)

[Checkboard]

Sad times for Indonesian aviation lately. :sad:

Monday, April 6, 2009
24 killed in Indonesia F-27 crash

Twenty-four Indonesian military personnel were killed Monday when their training aircraft crashed into a hangar at an air base in West Java, a hospital source said. The Fokker 27 was making a landing during a regular training flight when it crashed and burst into flames in Bandung, 74 miles southeast of Jakarta, an air force spokesman said. He could not confirm the final death toll but a doctor at the West Java hospital where the victims were taken said all 24 people on board the plane had died.

[CargoOne]

Wamena is very demanding airfield in terms of go around, climb with 180 very tight turn if I remember right, mountains from all sides but back. Short runway at ~4500ft elevation.

[fchan]

In 1979 I was at Sentani airport in West Papua. I watched Merpati land a medium sized jet (something like a 737 size). His approach was way too high 1/2 mile or so from threshold but, instead of going around, he just dropped the nose to head for the threshold and flared it out hard at the last minute. I have never before or since seen an aircraft approach with negative angle of attack with respect to the ground.

In around 2002 I was at Dili in East Timor on an Indonesian run plane waiting to leave. There was loud banging coming from the hold. Looking out the window you could see them trying to get the cargo door shut. It was clear to me that the crew were more interested in getting the door shut by any means, violent or not, than they were about damaging the door and causing a flight safety problem, as failure to shut it would have caused an expensive flight cancellation and layover as there were no maintenance facilities at Dili. I was rather nervous as we took off, but all was well.

[fchan]

CargoOne. yes most airfields around there are demanding due to mountains or jungle. I am not a pilot but as pax, I went to Sentani/Jayapurea, Wamena and a jungle strip south of Wamena. The latter was rather narrow and the Islander’s wingtip clipped the leaves on a tree upon takeoff.

Interestingly there was a lot of freight going inland from Sentani as there were no roads to carry all the cement, etc. needed inland, but almost no freight coming out. So you bought your ticket to go inland and just hopped on any passing plane without a ticket to return. Don’t know whether this system still exists. Must cause insurance problems as how do you pin your injury/death on the operator if you have no ticket?

[CargoOne]

fcan

Jayapura is more or less "easy" airport, reasonably long runway and close to sea level, no high terrain on approach/departure.
Don't know about other "jungle" destinations around but there wasn't any problem to buy a ticket to Wamena and back.

[Doors to Automatic]

It is no coincidence that every single operator from Indonesia is barred from European airspace.

[Teddy Robinson]

Once again .. its an airframe crashed, not a killer airframe.

[Tandemrotor]

Wow!

16hrs after the accident and you already know the cause. And presumably from the other side of the World too...

Good work! :D

[captainspeaking]

Tandemrotor

A little brusque, perhaps. Reports from the site said that the aircraft struck the side of Gunung Pike Mountain on approach to Wamena Airport and burst into flames. Sounds like CFIT to me. Even on the other side of the world. What we don't know is why it hit the mountain.

[JanetFlight]

Twenty-four Indonesian military personnel were killed Monday when their training aircraft crashed into a hangar at an air base in West Java, a hospital source said. The Fokker 27 was making a landing during a regular training flight when it crashed and burst into flames in Bandung, 74 miles southeast of Jakarta, an air force spokesman said. He could not confirm the final death toll but a doctor at the West Java hospital where the victims were taken said all 24 people on board the plane had died

Checkboard...24 souls inside a training flight...weird:rolleyes:

[False Capture]

I have never before or since seen an aircraft approach with negative angle of attack with respect to the ground.

Bunting into the runway is never good.

[Bullethead]

I have never before or since seen an aircraft approach with negative angle of attack with respect to the ground.

Watch a C130 make an approach, the nose is a little below the hoizon while most jets are a couple of degrees or more nose above the horizon.

Not necessarily negative angle of attack just a nose low attitude.

Regards,
BH.

[Otto Throttle]

Checkboard...24 souls inside a training flight...weird

I believe that particular accident was a para-drop training flight. The trainees were paras, not flight crew.

[Tandemrotor]

the aircraft struck the side of Gunung Pike Mountain on approach to Wamena Airport and burst into flames.

That's it then.

Case closed.

Cancel the AAIB! :ugh:

Was it the 'mountain' the 'airport' or the 'flames' that led you too such an insightful conclusion??

What we don't know is why it hit the mountain.

It sounds like captainspeaking and Teddy know. :rolleyes:

Personally I prefer this kind of approach:

Why? We don't know why the aircraft crashed; we don't know if it was an aircraft or system failure or pilot error. In many crashes the crew are just passengers in the final stage.

Does it sound familiar CS?

[lomapaseo]

In many crashes the crew are just passengers in the final stage.

Pretty rare, especially when they hit the side of a mountain on approach

[twotters]

I have landed in Wanema often during my time in IND. The airport is challenging being right in the mountains and at 5,085 ft MSL. Guess the a BAe146-300 is at its limits for T/O. Also the cloud coverage from 1000 onwards can be pretty nasty.

Anybody been there recently?

[Massey058]

Go into Wamena regularly, its great for a Caravan but have always marveled at the BAe 146 coming in.

Obviously everything is speculation until the report comes out, not that much stock can be put in a report from DCCA/NTSC. Apparently the initial scene examination was 'interesting'.

There is no instrument approach at Wamena. Apparently PK-BRD popped out of the cloud was high and did a go-around on Runway 15 (they never used 33 as maneuvering at the southern end for landing would most likely be impossible for a BAe 146 and have seen some pretty stiff tailwinds taken). Where the aircraft impacted terrain is around 500 feet AAE and roughly in the base leg area.

[Silver Spur]

JanetFlight,

It was not a Training Flight as such. It was the training sortie for the Paratroopers, so, it was "training" or "exercise":ok: for the parachute jumpers.:ok:

[JanetFlight]

Tanx for the Info:ok:

[Enderby-Browne]

Why are some of the instant experts here so sure of the C in CFIT?

[remoak]

Because it is by far the most likely explanation?

The 146 is pretty nimble in confined spaces, even with an engine out, compared to most other jets. That, combined with the accident record of the 146 - there has never been an accident involving loss of life that was due to a mechanical or structural failure - lends even more credence to the CFIT theory. Not that we should jump to conclusions of course...

[Massey058]

Why are some of the instant experts here so sure of the C in CFIT?

The reality is its an all too common occurrence and I think we all want it to stop. Maybe the true cause will never be known and at the end of the day everything here is all SPECULATION.

Since 2000 in Papua there have been 5 CFIT accidents (only counting aircraft Twin Otter size and below), and still the same casual factors that lead to those accidents are still in play today.

Another BAe 146 is on the way to Sentani as the Sentani-Wamena run was profitable, I sincerely hope that this one lasts until its parked up - in one piece.

[captainspeaking]

Enderby-Browne:

Why the snippy use of "instant experts"? I was just applying logic and experience to the reported information. I may be wrong - I'd be the first to admit it if good evidence to the contrary emerges - but CFIT does seem to be most likely. And I doubt if anyone on this forum would seriously suggest that a Pprune posting implied that an AAIB investigation was redundant. That would be very silly, wouldn't it? But every time that a Ppruner dares to post a theory or suggestion for the cause of an accident before any report is published, there is some Angry of Tunbridge Wells bursting to flay the hide from our body. Calm down, it's only a Forum.

[aw ditor]

Was it not "Disgusted of Tunbridge Wells"?

[captainspeaking]

Was it not "Disgusted of Tunbridge Wells"?

Probably, but you mistake me for someone who gives a damn! I think I'm just too old and grumpy for this form of social interaction.

[punkalouver]

http://www.dephub.go.id/knkt/ntsc_aviation/baru/pre/Final_Preliminary_Report_PK-BRD.pdf

[Dream Buster]

1.11 Medical and Pathological Information
The flight crew were examined for identification purposes, but no pathology or toxicology examinations were conducted.
Why not?

DB :mad:

[nannodnai]

Why not?


Just continue reading, and only a couple of inches further down it says:


2 CONCLUSION
The investigation is continuing and will include the meteorological conditions; Advisory Flight Information Service; weight and balance and certification information relating to the passenger/freight cabin reconfiguration of the aircraft; flight operations procedures leading up to the time of the accident; and pathology and toxicology issues in accordance with ICAO Annex 13.

[Dream Buster]

Many thanks nannodnai,

Are you aware of what "in accordance with ICAO Annex 13 means?"

Cheers,

DB :ouch:

[PEI_3721]

Dream Buster see Annex 13. (http://dcaa.slv.dk:8000/icaodocs/)
More details given in ICAO Doc 6920 AN/855/4 Manual of Aircraft Accident Investigation.

Based on the concluding remarks, we might assume that EGPWS was serviceable and thus provided warnings. In the situation described (ref to Google Earth) the alert period would have been quite lengthy. Thus, why didn’t the crew respond? Or if they did, why was it too late or insufficient to clear the ridge?
A visual circuit / circling procedure (i.a.w. a published procedure or not) should still be flown visually. If the aircraft is judged as going to enter cloud, or inadvertently does so then there should be an immediate pull up.
There are some similarities with other incidents where crews failed to respond correctly, in these events (http://www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf) there were mistakes in awareness and visual illusions; did the crew in this accident have an illusion of invulnerability?

[PK-KAR]

Don't know about other "jungle" destinations around but there wasn't any problem to buy a ticket to Wamena and back.
It's not the 'usual'... *grin*

Anyways, on the rumour mill is that the aircraft's speed was high during the turn to base, and went past the centerline and couldn't get away from that hill... whether it's true or not, it's a different story....

PK-KAR

[nannodnai]

Are you aware of what "in accordance with ICAO Annex 13 " means ?

Yes, I am; in particular paragraph 5.9 - - - - viz :


5.9 The State conducting the investigation into a fatal
accident shall arrange for complete autopsy examination of
fatally injured flight crew and, subject to the particular
circumstances, of fatally injured passengers and cabin
attendants, by a pathologist, preferably experienced in accident
investigation. These examinations shall be expeditious and
complete.
Note.— Guidance material related to autopsies is provided in detail in the
Manual of Civil Aviation Medicine
(Doc 8984) and the Manual of Aircraft Accident Investigation
(Doc 6920), the former containing detailed guidance on toxicological testing


So it's reasonable to expect that that's what will happen . . . . .. . isn't it ?

[GBV]

Final report:

http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final%20Report%20PK-BRD.pdf

[Teddy Robinson]

CVR indicated that the copilot instructed the PIC “overshoot,
overshoot” after the second of the five ‘WHOOP WHOOP, PULL UP’
sounds. The FDR showed that the aircraft commenced a go around from
a low height above the runway. The controller offered the crew a choice
of a landing on runway 33, but the crew elected to make a right circuit
for runway 15.
The circuit was flown at a height of between 150 and 350 feet above the
aerodrome elevation.
The CVR provided evidence that during the downwind leg the EGPWS
fitted to the aircraft provided the flight crew with eight ‘DON’T SINK’
and one ‘TOO LOW TERRAIN’ voice aural alerts. The flight crew did
not respond to any of those alerts.

The Operator’s BAe-146 Flight Simulator Training Program
The operator’s BAe-146 Flight Simulator Training Program for the
flight crew did not cover training and checking of pilot actions and
responses to the EGPWS aural alerts and warnings.

Thank you GBV

[CargoOne]

I was wondering about conversion of this airframe, because I never heard about 146 Combi before. Althouth nothing to do with the accident in question, still interesting...

During the investigation it was determined that the aircraft manufacturer
had not issued a manufacturer-approved modification for a combined
passenger and cargo version of the aircraft type.

Shall anybody call DGAC and advise about some other aircraft types there having similar in-house "conversion"?

[Dream Buster]

I'm not at all surprised that no pathology or toxicological tests were made.

In 2006 UCL (University College London UK) tested 27 BAe 146 and B 757 pilots and found they all had highly abnormal amounts of toxic chemicals in their blood / fat and measurable cognitive dysfunction.

http://www.aerotoxic.org/download/docs/reports_and_evidence/cjne%20paper.pdf

Would you look for the vital clue that would explain a fatal accident - If the results were inconvenient. Perhaps they forgot?

Cover up and they know it - but how do they continue to get away with it?

DB :mad:

[PK-KAR]

Circuit flown at 150 - 350' AGL immediately after a missed approach...
Recipe for disaster... they overshot the centerline and the Capt. appears to have been caught with a little confusion... the 2 hills are supposed to be to his left in the turn to final, but ended up being caught between the 2... with no sight of the runway (blocked by the 2nd hill, which they flew into). But then, I wasn't there...

Shall anybody call DGAC and advise about some other aircraft types there having similar in-house "conversion"?
Well, there's the F-28 converted to cargo by Gatari... operates (or planned to) the same route as the Aviastar 146. For Wamena... anything imported from outside the valley gets flown in!

Would you look for the vital clue that would explain a fatal accident - If the results were inconvenient. Perhaps they forgot?
What would be needed for the test? Wamena is pretty remote by our standards, and I wouldn't be surprised if the hospital would run out of certain stuff on a regular basis... but yes, it would have been better with...
Unfortunately, the culture here seems to resist post mortem examination, unless it was a crime scene. :(

[Dream Buster]

PK- KAR,

It would be totally wrong to suggest that The Indonesians are the only culture that resists a thorough post mortem of the crew following a fatal accident - as the rest of the world does exactly the same - as little as they can get away with.

Even the so called 'First world' of the UK?

That's the whole point. And still they get away with it....

DB :ok:

[aseanaero]

Aviastar are readying a proper 146-100 Cargo for ops to Wamena now.

Another problem with the old 'Wamena Combi' conversions is they don't have proper cargo load restraining points and 16g cargo barriers. It's possible that the load was shifting around during these banking and pitching maneuvres , word was it was carrying about 9,000 litres of fuel in drums and heavy bags of food stuff.

[remoak]

Dream Buster

Most first-world (and a number of third-world) will do enough pathology to screen for drugs and alcohol... most will look at the heart as well. What they don't tend to do is look for signs of OP poisoning, which is of course the subject of some debate... ;)

Perhaps what should be examined is the role of slow, partially incapacitating illnesses, particularly those that affect judgement in such scenarios as the Wamena accident. Don't hold your breath, though...

[Dream Buster]

Remoak,

Well, as a BAe 146 pilot I stopped flying after 16 years on the aircraft as my memory was awful and I didn't feel safe any more.

A year later, when they tested my blood / fat, they found it full of OP's and a cocktail of other chemicals plus measurable cognitive dysfunction.

Don't you think it might be appropriate for 'first world' countries to check the blood / fat of deceased pilots for OP's?

The only doubt seems to be in vested interests parties - ask any victim who has been affected and they will tell you that they know - 100%.

Here is the contact for getting tested:

Dr John McLaren Howard

Acumen
PO Box 129
Tiverton
Devon
EX16 0AJ.
Tel: +44 (0)7707 877175.

If you rely on the State NHS test - they will tell you are OK, as your blood is - red.

DB :ok:

[remoak]

Dream Buster

Yes, I was in fact agreeing with you... :ok:

Anything that MIGHT be a factor SHOULD be tested for.

[BoeingMEL]

..but let's not forget that those 2 "professional" guys broke so many basic rules. SOPs? MSA? CRM? Indonesian operation yet again... no surprises here then. Is the EU ban still in force? Such a needless and tragic waste IMHO. bm

[PEI_3721]

This accident could be the first involving Enhanced GPWS (EGPWS), but the evidence suggests that the system was turned off after the first approach. Thus, a major contributor could have been a crew operating error.
These errors often have origins in the crew’s understanding of systems, which in turn depend on training and individual willingness to learn / recall information.

Some people cite the problems of geographic or cultural differences. However, the types of crew error indicated in the report are seen in most, if not all areas of the world; fortunately not so frequently as to require bans or operating restriction.

There is still much that everyone should learn from this accident; if nothing else, do not turn off terrain warning systems.

[Capn Bloggs]

the evidence suggests that the system was turned off after the first approach.
How would you turn the EGPWS off, apart from pulling CBs?

[PEI_3721]

The accident report describes the EGPWS installation and system switching; it is typical of most aircraft installations. Pushing the ‘Terrain OFF’ illuminated push button on main instrument panel inhibits the ‘Enhanced’ functions, but leaves the basic GPWS modes active.

An incident in N America involving an A320 where the crew inhibited EGPWS is described at item 8 in TAWS ‘Saves’ (http://www.icao.int/fsix/_Library%5CTAWS%20Saves%20plus%20add.pdf) - a very near miss.