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Monday, April 23, 2012

UPDATE: Batavia A320 overrun at BPN 12MAR12

EU Ban exempted carrier Batavia A320 runway excursion
On 19th April, Indonesia's National Transportation Safety Commission has released its recommendations for the Batavia Air A320 PK-YVE overrun at Balikpapan that occurred on 12 March 2012. My summary translation of the finding can be found later in this article (with link to source).

What I find disturbing:
  • Batavia Air is an airline that is exempted by the EU Ban imposed on Indonesia.
  • Aircraft has had problems with nose wheel steering and brake systems since November 2011.
  • This incident is the second runway excursion in recent months.
  • Airbus has issued recommendations to Batavia Air on fixing the issue prior to the aircraft flying again.
  • Batavia Air did not complete the work outlined in the Airbus recommendation before its next revenue flight.
  • The combination of brake servo valves installed in the aircraft did not comply with Airbus Service Bulletin issued.
  • A Key personnel holding key holding the Technical Director position at the airline was different from the one specified in the airline's Operations Specification document approved by the DGCA.

Credibility of EU Ban and EU Ban Exemption questioned
The EU Ban Exemption for Batavia has raised questions amongst the industry, and the credibility of the EU Ban and its exemptions in particular. With the country now focusing more on raising the FAA Country Category II status back to Category I, the NTSC investigation into the PK-YVE excursion will certainly raise more questions on how Batavia Air received its exemption from the EU Ban, whilst others such as Lion Air who has put in a great effort into safety improvements (with a lot of help from Boeing and ATR), remain in the ban.

Indonesia now has no problems in admitting that the EU Ban and FAA Country Category II "sentences" were caused by safety deficiencies, but seeing which airlines got on the exemption list and which airline remains on the country blacklist is causing a lot of grievances, including allegation of unfairness and political favouring by the EU. The slap in the face for the EU Ban is Indonesia's decision to literally, "screw the EU Ban and let's focus on getting our FAA rating back to Country Category I", and to work with other countries regulators and safety agencies such as Civil Aviation Safety Australia (CASA), Japan Civil Aviation Bureau (JCAB), and even regulators from individual EU member countries. Work with EASA continues but without looking at the EU Transportation and Energy Commission's work.

I guess the conclusion of the country's new direction in safety improvements and the findings into this serious incident investigation is, "yes, we got problems, we're solving it, but we'll get help from those we can trust, screw your ban!"

Summary of findings:
PK-YVE operated BTV2911 from Denpasar to Balikpapan with 2 pilots, 5 flight attendants and 178 passengers (including 1 engineer and 1 pilot not on duty).

Aircraft landed on 0327UTC at runway 25 Sepinggan Airport, Balikpapan (BPN/WARL). At around 150 meters before the runway end, aircraft veered to the right and pilot attempted to steer the aircraft back onto the centerline. Aircraft stopped at the stopway beyond the runway 07 threshold, and all 4 wheels of the main landing gears sunk 30-40cm into the asphalt.

Airport was reopened with a NOTAM advising that the runway usable length was reduced to 2040 meters. Aircraft evacuation was delayed because the required A320 main landing gear jacks had to be sent from Jakarta. Aircraft was moved onto the apron at 1725UTC on 13MAR, and the reduced usable runway length NOTAM was terminated/revoked.

Early investigations have found that PK-YVE has suffered from steering and brake system problems since November 2011. 

Aircraft was found to have 2 different sets of brake services: 2 units of new model brake servo valve (p/n C20374000-2) and 2 units of older brake model servo valve (C201033500).

Servo valve combination is found to be in Non-compliance to Airbus service bulletin (A320-3201089 revision 3) issues 20 September 1995, which when non-identical brake servo are instaled, mandated operators to use 3 new model servo valves (C20374000-2) and 1 old model servo valve (C20103100, C20103100-1 or C20103500).

Early NTSC investigations have found that between the aircraft being moved off the runway and the repairs done by Batavia engineers, poor coordination was shown and is a result of poor understanding of procedures and lack of effectiveness of field key personnel.

The person holding the Technical Director position at the time of the incident was different from the person specified in the Operations Specification document approved by the Directorate General of Civil Aviation (issued 18 January 2012).

The serious incident is the second runway excursion suffered by PK-YVE in recent months, the first one occured on 7 February 2012 at Sentani Airport, Jayapura (DJJ/WAJJ).

The NTSC noted that since the February excursion, Airbus has provided several subsequent checks for PK-YVE to Batavia before the aircraft can be flown again. It appears that Batavia has deemed the problem solved as the aircraft maintenance computers had not reported any faults. Another finding suggests that the engineering personnel may not have understood the pilot report with regards to faults in the brake system. The investigation reveals that Batavia has only partially achieved/completed part of the Airbus recommendations, and the work outlined in the recommendations remained incomplete by the time of the Balikpapan excursion.

Summary of recommendations:
The NTSC has issued the following recommendations:

Batavia Air:
  • To obey and execute recommendations made by the manufacturer on brake and nosewheel steering systems.
  • Improve and ensure the control system on the aircraft configuration remain and continue to comply with the Illustrated Parts Catalogue, Service Bulletins, and recommendations issued.
  • Ensure the status and conditions of the manuals and procedures to be valid and updated and can be accessed by personnel when required, especially in outstations.
Balikpapan Airport
  • Review the Emergency Response Plan on handling of incident/serious incident/accident.
  • To cooperate with other agencies and airlines within the airport environment to provide mutual assistance and support in handling incidents/serious incidents/accidents.
  • To include obstacle location and height when issuing NOTAMs.
DGCA - Airworthiness Directorate
  • Ensure that Principle Maintenance Inspectors me more aware and understand aircraft repetitive problems.
  • Ensure that Key Personnel duties are carried out by persons specified in the valid Operation Specification
  • Ensure that operators have better control systems over aircraft configuration and manual status.
DGCA - Air Navigation Directorate
  • To include obstacle height and position when issuing NOTAMs caused by obstacles, to be used as reference when calculating aircraft operational performance
Source: Immediate Safety Recommendations - Serious Incident Airbus A320-231 PK-YVE Balikpapan Sepinggan Airport 12 March 2012 - National Transportation Safety Commission (Rekomendasi Segera Kejadian Serius Pesawat Airbus A320-231 Registrasi PK-YVE Di Bandara Sepinggan, Balikpapan, Tanggal 12 Maret 2012, KNKT/001/3/IV/REK.KU/2012)

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