NTSC final report on PK-MZK MA-60 in Kaimana: Familiar causes!

Previous articles:

Let's be fair shall we? (17 May 2011)

Dropping the dead donkey! The Merpati MA-60 crash at Kaimana continued (22 May 2011)

Indonesia's National Transportation Safety Commission today released its final report on the Merpati MA-60 (PK-MZK) accident in Kaimana that occured a year ago, on 7 May 2011. Little has changed on the causes of the accident since the preliminary release made just under a year ago. Controversy surrounding the aircraft airworthiness is not under question as the probably causes of the accident reveals to be more human, and eerily familiar... that is, conducting a visual approach under instrument meteorological conditions.

The accident flight ended with the aircraft hitting the water 800 meters to the south-west of the beginning of runway 01, after a failed go-around attempt, killing all 25 on board. The crew had attempted to conduct an approach into Kaimana's Utarom airport, amidst rain conditions with a 2 kilometer visibility and 1400ft cloud base. Unfortunately, the airport has no instrument approaches and any approaches are to be made visually, requiring visibility of 5 kilometers or better. Instead of holding or diverting, the crew continued to attempt the approach.

The final sequence summary:

Finale sequence of PK-MZK (Source: NTSC)

The aircraft impacted the water 800 meters from the runway, broke into 5 large pieces and debris was strewn across a 100m by 200m area on the sea floor 7 - 15 meters below the surface. Landing gear lever was found in the up position, flap lever in the up position, and the power levers in the forward position, and the engine condition levers in the maximum forward position.

Late go-around, loss of situational awareness, and breakdown of CRM

The investigation found that no approach briefing was made, and that the crew were preoccupied in finding the runway which lead to reduced situational awareness, amplified by PIC taking over from the SIC without adequate explanation. When the aircraft reached the "minimum" at around 500ft, approach was not immediately aborted and the PIC instead asked the SIC three times whether or not he could see the runway or not, before finally aborting the approach. Instead of aborting at 500ft, the aircraft had gone as low as 376ft before peaking at 585ft and then the subsequent descent to impact.

The investigation found that the disastrous go-around was a "loss of situational awareness due to a strong intention of the crew to find the runway in poor visibility" and exacerbated by the flap retraction to 5 at low speed (below the required 135kts).

Findings and Factors:

• Visual Flight Rules approach in Instrumental Meteorological Conditions should not have been attempted.
• Crew did not conduct approach checklist or conduct approach briefings.
• The lack of approach briefing exacerbated the impending danger of attempting to conduct a visual approach in unsuitable condition because the crew did not synchronize their plan of attack.
• Engine Regime Selector (ERS) was not selected to TOGA during the go-around or in the approach (as required by the approach checklist). This limited the engine Torque to a maximum of 85.6% instead of 106.3% for TOGA.
• Crew lacked situational awareness by trying to find the runway, and then discontinued the approach.
• Crew actions of retracting flaps to 5 then up, less than go-around power, and increased roll up to 38 degrees left bank led to rapid descent impact with water. 
• Both crew had low experience on type. Both PIC and SIC had less than 250hrs on type. This situation may have contributed to the accident.
• Evidence indicating steep cockpit authority may have added to the breakdown in crew resource management.
• Inadequate / ineffective training program may have lead to deviations from standard procedures and regression to habits associated with previous aircraft type.  The "flaps at 25" and retraction to flap 5 during the go-around also reflect the PIC's previous type rating, the Fokker 100. This could be exacerbated by lack of training in a new type.
• There was no evidence that the crew had received EGPWS training.
• The FCOM and Aircraft Maintenance Manual used non-standard English Aviation Language. Although this does not directly contribute to the accident, it could have caused confusion.
• Flight Operations Quality Assurance had not been implemented and the airline had not been effective at implementing the Safety Management System in all management levels.
• DFDR (Digital Flight Data Recorder) did not comply with Indonesian  CASR 121.343 and 121.344 requirements. It did not record lateral and longitudinal acceleration as required (Chinese Civil Aviation Regulations 121 did not require these two parameters).

Since the accident, the NTSC reported that the DGCA has audited Merpati Airlines, and that  the Safety Management System have been implemented at all management levels in Merpati. Merpati itself has issued various internal safety recommendations as a result of this incident.

It's not the first time for Merpati...

However, as a consumer and member of the general public, I cannot help but wonder, if safety improvements will prevail in Merpati. Afterall, just a year before PK-MZK, a Merpati 737-300 overran the runway at nearby Manokwari, and again, it was conducting a visual approach in instrument meteorological conditions, just like in Kaimana. That 737-300, PK-MDE, though had no fatalities, was written off after that spectacular accident!

Sources:

NTSC Press Release on PK-MZK Final Report (English)

NTSC Press Release on PK-MZK Final Report (Indonesian)

NTSC Final Report PK-MZK

NTSC Preliminary Report PK-MDE

All sources can also be found at NTSC original site.

The Merpati Question Part 2: Predators vs Pigeons

The plight continues...

It is almost a year since I wrote "The Merpati question: How do you rescuscitate a dead pigeon" and Merpati is now coming up to its 50th anniversary.

Whilst the turnaround at the prime state owned carrier Garuda, is now beginning to finally produce profits, Merpati remains in limbo. I wonder how much more things can go wrong there...

The CEO's rant at the parliament's 6th commission last year of "Look at Air Asia. One should look and ask if any regulations have been violated. (If not, then) The regulations should be reviewed. There is no way for anyone to operate the A320 profitably on short haul!" seems to have been followed by Merpati planning to add A320s to its fleet middle of this year. Bizarre!

Then in October last year, state oil company Pertamina refused to supply fuel on credit to Merpati, citing fuel debts of $62.15 million. Fuel supply was restored when the state's Asset Management Company (PT Perusahaan Pengelola Aset) guaranteed restructuring of the debt worth $63.39 million.

Is the MA-60 the current flagship
of Merpati?

In February, they also signed an MOU with COMAC for 40 ARJ21-700 at the Singapore Air Show. If the deal goes ahead, this would be the biggest order for the type outside China. However, it appears that COMAC didn't want the signing to be well publicized outside China and Indonesia, asking for the journalist present not to publicize it. However, the signing made news allover Indonesia. It all sounds strange, but after all, Merpati is also the largest operator for the AVIC MA-60, and many still question the decision to go for that aircraft type.

Then, came the video for Merpati's upcoming 50th Anniversary, uploaded on 4th April 2012.

In short, I think the video meant:

"We screwed up in the past, so we now have to make it better. We're sorry, and change, is the only way for Merpati to survive. So, we've got comfortable MA-60s now, so what we have to do is to fill it with passengers with no excuses! So let's get to work." The video ends with a quote, "Doing the impossible!"

Garuda could end up operating the
Dash8-Q400

The talk on whether or not Merpati should be saved continue as we speak. Much of the principle business question is, "what role should be filled by Merpati, as a state owned company." But before a consensus short list of answers can be gained, a major threat to Merpati's future came today with Garuda's announcement published in Flightglobal, that it plans to buy either the ATR72 or Bombardier Q400 for low-density routes in eastern Indonesia.

A Wings Air ATR72 about to land
at Denpasar's Airport, Bali

While this plan will bring Garuda in direct competition with Lion Air group's ATR operations under Wings Air, citing the words "to serve low-density routes in eastern Indonesia" means Garuda intends to attack Merpati's bread and butter market (whatever is left of it)!

So, as Merpati's 50th anniversary is coming up, the giant mythical eagle, the Garuda, plans to attack the pigeon and the pigeon (a.k.a. Merpati) still hasn't recovered from the ATR onslaught of Lion, which coincidentally was announced near Merpati's 45th anniversary, 5 years ago.

Is the pigeon able to defend itself from the eagle and the lion? Could it be better to simply stop feeding steroids to the pigeon and just cook it while it still has value? Or is it better to continue feeding it, only to be eaten alive by the eagle and the lion?

Dropping the dead donkey! The Merpati MA-60 crash at Kaimana continued

Continuing on from "Let's be fair shall we?" blog article , I had complained about all the talk in the media and politics being irrelevant to the accident (they can rattle their sabers all they like). In that blog article I mentioned that the visibility was 2 kilometers and that the visual approach into Kaimana in that condition would be illegal.


Some have asked me in private where I got the information from (most of the media articles only mentioned "bad weather") and few have even said, "how dare you accuse?"


Today I come across two links related to the accident that occured on 7th May:

1. Aviation Safety News - interim safety recommendations from the National Transportation Safety Comission
2. Preliminary accident investigation report from the NTSC (in Indonesian)

The report mentioned:

• Kaimana has no instrument approach procedures, therefore the approach has to be performed under Visual Flight Rules.
• Weather information (at 0300Z) for Kaimana prior to departure was 8km visibility, 4/8 cloud cover at 1400ft cloud base, wind from the south east at 6 knots and surface temperature was 29C. The flight was legal to start.
• Passing JOLAM At 0425Z, aircraft provided an ETA of 0454Z to Kaimana AFIS. Kaimana AFIS reported the weather conditions as: 3-8km, few cumulonimbus with cloud base f 1500ft, wind from south west at 3knotd and surface temperature of 29C.
• At 0430Z aircraft descended from 15500ft, and was requested to report again 5 minutes out.
• At 0442Z, aircraft reported 7NM out passing 8000ft. Crew asked if it was still raining and was replied that it was, and they decided to proceed to the south of the airfield.
• At 0445UTC, aircraft reported to be 15NM south of the airfield at 5000ft and waiting for a change in weather. Airport was still raining with 2km vsibility.
• The last contact with the aircraft was around 0450Z where the crew asked if the visibility has changed. AFIS replied that the visibility was still 2km and that the threshold of runway 01 can be seen from the tower.
• The aircraft impacted at roughly 800m south east from runway 01, 500m from the coastline. Most of the wreckage sunk in shallow waters of 7 to 15 meters deep.
• AFIS received reports from eyewitness as the impact location was obscured from the tower by trees.
• Aircraft was destroyed, 25 people had died.
• FDR was retreived on 9th May and the CVR retrieved the next day.

Safety Actions:

• DGCA has conducted an audit of Merpati since 10th May.
• Merpati has issued a safety recommendation on 11th May:
• Aircrew are reminded to abandon the approach/landing if the conditions dictate.
• Pay attention to the visual flight rules and instrument approach minimum
• Observe the 9 criterias of a stabilized approach.
• Reinforce the mandatory training and simulator sessions including windshear, CRM, approach landing accident reduction and go-around indoctrination.
• Dispatchers to provide the latest weather information and anticipate flights to Return To Base.
• Ensure technical inspections on pre-flight, transits and daily checks as per the checklists and immediately report each finding to the Maintenance Control Center.

The NTSC has issued the following recommendations:

• To Merpati Nusantara Airlines:
• Ensure that visual flight is being conducted in accordance with VFR conditions, and conduct training on the MA60 Crew Simulator with an emphasis on CRM in the face of the bad weather.
• To the Director General of Civil Aviation:
• Monitor the implementation of the recommendations in point A , to be carried out  by Merpati Nusantara Airlines.
• To Directorate General of Civil Aviation and Directorate of Airports:
• Review the provisions of the use of facilities / equipment, especially the airport runway lights to enhance the safety of flight operations, especially in low visibility conditions.

So, whilst the facts has been established, the question remains, WHY DID THEY ATTEMPT AN APPROACH BELOW MINIMA? (in the meantime, politicians and born-yesterday heroes can continue to rant senselessly!)

The Merpati question: How do you rescuscitate a dead pigeon?

Indonesia's two state owned carriers are poles apart. Whilst Garuda is rapidly reducing its losses whilst undergoing a major turnaround effort and an IPO, it's sibling, Merpati, continues its slide into doom. There appears to be no end to Merpati's slow death as no one is willing to put it into a major turnaround like Garuda, and no one is willing to bravely say enough is enough.

Merpati's managements' public comments are nothing short of laughable or clueless. In an article at Detik.com (link to article) in March, the CEO complained in a parliamentary hearing on the DPR's 6th commission (covering transportation and state-owned enterprises). There, he complained about several things:

1. He felt that Merpati's business was being affected by Garuda's LCC arm, Citilink. He stated that Citilink should be abolished, "There is Merpati, why is Merpati allowed to be poked around? Both are owned by the government and the money made goes back to the government anyways!"
2. He felt that Citilink should not be considered at all as it operates under Garuda's AOC. "If it has its own AOC, then we can talk!"
3. He went further to attack LCCs. According to him, the LCC concept has been violated by airlines in Indonesia and that the regulations must be changed for a more level playing field. "Look at Air Asia. One should look and ask if any regulations have been violated. (If not, then) The regulations should be reviewed. There is no way for anyone to operate the A320 profitably on short haul!"

So, whilst he was attacking the LCC operations, he then stated, "Merpati is going aiming to be a premium carrier with full services."

I personally wonder how the CEO selection process was made.

I leave it to you all to judge based on the following:

• Citilink and Merpati, compete on 2 routes. Jakarta-Surabaya with Citilink 6x daily (Merpati 2x weekly), Jakarta-Makassar, and Jakarta-Denpasar with Citilink 1x daily (Merpati 4x weekly).
• A320 short haul operations can be profitable. Indonesia Air Asia posted a massive leap in profits for 2010, and is the country's largest A320 operator, and also the most profitable carrier on a per-aircraft basis.

Let me end this short rant with the question and a choice of answers:

"How do you resuscitate a dead pigeon?"

1. No need, cut it's head off and end it's misery?
2. Use a defibrillator for an elephant?
3. Shove a cyanide pill down it's beak?

Haven't we had enough of shoving our tax Rupiahs for the dead pigeon?
The story continues at The Merpati Question Part 2: Predators vs Pigeons


(Thanks to Riazy for the corrections on the competing routes!)

Bisa fair gak yah kita?

Kecelakaan MA-60 Merpati di Kaimana memicu diskusi dan perdebatan mencapai titik ngawur beyond belief. Selama in saya males posting mengenai ini di social media demi menjaga akal sehat saya, namun, diem juga panas ngeliat yang lain meng-asbun!

Kebanyakan dari debat nya mutar-muter di "pesawat bikinan Cina", "gak ada sertifikasi FAA", dan "Ngapain kita pake pesawat bikinan Cina? Kan kita ada CN235?"

Hal yang menggelitik dikepala saya adalah tidak ada satupun yang koar-koar masalah fakta seputar kecelakaan itu sendiri. Bandara Kaimana memiliki 1 NDB dan tidak ada instrument approach procedures. Artinya, mau mendarat disana harus melakukan visual approach dimana jarak pandang harus 5 kilometer atau lebih. Dibawah itu, sorry, illegal!

Semua orang mencuap-cuap mengenai buruknya MA-60, dan semua tidak ada yang mau melihat bahwa pada saat kejadian, jarak pandang di Bandara Kaimana dilaporkan hanya 2 kilometer... YA!! DUA KILOMETER ! Mau coba mendarat pakai CN235 atau ATR atau pesawat lainnya dan jatuh... orang-orang masih mau nyalahin pesawatnya kah?

Saya denger-denger dari "koboi-koboi" dan pasukan pendukungnya, kalau mau mencoba masuk dengan kondisi cuaca dibawah VFR Minimum (5 kilometer jarak pandang tadi), mereka menggunakan GPS. GPS tentu saja bisa memberikan panduan setingkat VOR/DME approach, namun membutuhkan GPS yang sudah di-approve untuk digunakan dalam approach dan harus menggunakan approach procedure GPS yang sudah resmi (alias bukan bikinan sendiri, atau menggunakan waypoint untuk guidance only).

Jika sedang "bermain dengan takdir", anda berada di area yang tidak ada perlindungan terlepas dari berapa kali anda pernah melakukannya. Ketika melakukan GPS approach yang ilegal, bagaimana ketika anda go-around? Kalau melakukan approach runway 01 di Kaimana, ingat, ada bukit-bukit di sebelah utara bandara dan escape path anda adalah belok putar arah 180 derajat ke kiri diatas laut. Ini kedengarannya gampang tetapi jika anda melakukan beloknya secara visual, jangan kaget kalo anda kena spatial disorientation!

Jadi, bisa fair gak kita? Saya tidak suka MA-60, menurut saya itu pesawat yang siap jatuh kapan saja, namun dalam kasus kecelakaan ini, lebih baik kita tidak terpaku dalam sudut pandang subjektif kita dan melihat kejadiannya secara objektif! NGAPAIN COBA MENDARAT KALO KONDISI CUACANYA MENGAKIBATKAN ANDA MELAKUKAN APPROACH YANG ILEGAL?

Kapan yah bangsa kita bisa berhenti menyalahkan apa saja selain kita sendiri di saat dimana yang salah itu memang cuman kita sendiri? Bisa fair gak yah kita?

Let's be fair shall we?

The Merpati MA-60 accident in Kaimana have stirred the country to the point of being ridiculous. Whilst I have kept away from its discussions in the social media to keep my sanity, sometimes, one just cannot stay quiet!

Most of the debate have evolved around "aircraft made in China", or "it is not FAA certified", and, "Why are we using planes made in China when we have our locally built CN235?"

It is very disturbing that no one seems to bother to check the basic facts of the accident. Kaimana Airport, has 1 NDB, but no instrument approach procedures. To land at Kaimana airport, one has to approach visually, meaning, the visibility has to be 5km for you to even start the approach, otherwise one would be illegal.

So with all this talk about how bad the MA-60, everyone seems to ignore the fact that weather at the airport was reported at 2 kilometers, yes, TWO kilometers. Do this on a CN235, an ATR, or any other plane, and crash... Would people still blame the aircraft?

I have heard "cowboys" and/or their backers say they can land below the VFR minimum by using the GPS. Sure, GPS can give you down to the equivalent of a VOR/DME approach but only if your GPS is approved for approaches AND if you are following a certified GPS approach procedure.

Now when you start "playing with fate", you're on uncovered territory regardless how many times you've been in that situation before. When you conduct an illegal GPS approach, what happens when you go-around? If you are approaching Kaimana for runway 01, remember the hills beyond the airport and that your escape path is to make a 180 left turn over the water. This sounds simple, but, to do so in instrument meteorological conditions while making the turn visually can and most likely will give you spatial disorientation!

Let's be fair here! As much as I do not like the MA-60, as much as I think it's a plane wreck waiting to happen, in the case of this accident one must not just look at one's view and be objective... WHY LAND WHEN THE CONDITIONS WOULD YIELD YOU AN ILLEGAL APPROACH?

When will people here stop blaming anything but ourselves when we have only ourselves to blame? Let's be fair shall we?

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