Post on 01-Jan-2017
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
Lessons Learn of the Sukhoi RRJ-95B Investigation
Mount Salak, Indonesia
9 Mei 2012
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KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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• An experimental aircraft, a Sukhoi RRJ-95B, conducted ademonstration flight on 9 May 2012 from HalimPerdanakusuma International Airport, Jakarta.
• On the second flight, the aircraft collided with terrain atMount Salak, 27 miles south west of Jakarta, at 6000 feetelevation.
• 41 occupants fatally injured.
• An experimental aircraft, according to the Russianregulation was not registered as civil aircraft.
• The Accredited Representatives was the deputy of theMinister of Trade and Industry of Russia and the adviserswere Interstate Aircraft Committee (IAC) and Sukhoi CivilAircraft Company (SCAC).
Synopsis
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
07:32:42 - HDG Sel 174
N
07:27:52 - Dark cloud ahead
07:32:05 - PIC commanded to request heading 300
07:28:21 - Approved orbit to the right 6,000 feet
07:31:42 - P1 : Ask for right turn for approach
07:29:27 - Aircraft reached 6,000 feet
07:30:44 - Pilot demonstrated the
terrain function of TAWS
07:33:19 - WARNING : “Gear not down” ... Chime 2x … Trickle sound 11x
07:32:56 - WARNING : “Avoid terrain" 4x ... Chime 1x
07:32:48 - WARNING : “Terrain ahead, Pull Up” … “Avoid terrain" 2x
07:33:24 - P1 : Auto pilot OFF
07:32:58 - P1 “maybe…..database” and inhibit TAWS system
07:32:51 - P2 : What is that?
07:31:00 - 07:31:38 - Pilots and guest discussed
related to the aircraft fuel consumption
07:29:36 - HDG Sel 150
07:29:25 - HDG Sel 103
07:29:16 - HDG Sel 093
07:28:39 - HDG Sel 033
07:31:47 - 07:31:58 - SIC called the PIC 3 times to
ask the PIC intention to make another orbit or
approach
07:32:13 - 07:32:25 - Pilots discussion to determine
the heading to return to Halim
07:28:59 - 07:29:37 - Pilot demonstrated the
convenience make holding pattern
07:32:39 - 07:32.46 - PIC commanded to request to
return to Halim
07:30:48 The pilot stated that at
that moment the terrain display
was not necessary. The potential
customer confirmed by “yes, its
flat”
07:30:14 - HDG Sel 174
07:32:44 - HDG Sel 325
07:31:53 - HDG Sel 174,
Aircraft HDG 174
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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• On the early stage of investigation, there was mutual
agreement between the President of Republic of Indonesia
and the President of Russia Federation that only Indonesia
and Russia participated in the investigation.
• The Singapore AAIB canceled the program for observation,
and the avionic and engine manufacturers could not sent
their Accredited Representatives.
• The investigation could not be fully conducted under ICAO
Annex 13.
• Russian crime investigators present however, NTSC
refused to deal with them.
Political Issues
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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• The accident site was in extreme terrain condition on85° slope at 6000 feet.
• Search and Rescue activities led by National Searchand Rescue Agency (BASARNAS) involving morethan 2000 personnel from the Indonesia Army, AirForce, Navy, Police, mount climbers and local villagersand Russian SAR team (80 personnel).
• Utilizing 6 helicopters (5 Indonesian and 1 Russian)
• The SAR operation terminated after most of thecasualties and black boxes were recovered.
Search & Rescue Operation
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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• Many conversation were in Russian.
• The transcript and interpretation process were
assisted by a Sukhoi test pilot as adviser,
Indonesian embassy staff of Uzbekistan and an
Indonesian citizen who speak Russian fluently.
CVR Transcript
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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• Major accident involving last generation of aircraft,
manufactured by Russia, has attracted attention of
the media.
• “Aviation Experts” have made some assumption to
the cause of the accident and built the public
opinion.
• NTSC has to explained in the report, to correct the
public opinion.
Media / Public Issues
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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Emergency Locator Transmitter (ELT) 406
Antenna connection
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NATIONAL TRANSPORTATION SAFETY COMMITTEE
The Black Box
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KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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The public release of the final report was on 18 December 2012.
The investigation concluded that the factors contributing to this
accident were:
• The crew were not aware of the mountainous area surrounding
the flight path due to various factors resulting in disregarding the
TAWS warning.
• The Jakarta Radar service had not established the minimum
vectoring altitudes and the system was not equipped with
functioning MSAW for the particular area surrounding Mount
Salak.
• Distraction to the flight crew from prolonged conversation not
related to the progress of the flight resulted in the pilot flying did
not continue to change the aircraft heading while in orbit.
Consequently, the aircraft unintentionally exited the orbit.
Final Report
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
Attention Mr. Tatang Kurniadi
CHAIRMAN
NATIONAL TRANSPORTATION SAFFETY COMMITTEE
Dear Sir,
Let me express to you my gratitude for the draft of Recommendations, which I received on 13th of June 2012.The document was examined carefullyPlease kindly note, that this version of Immediate Recommendations is agreed by all Russian officials, involved in accident’s investigation process.
Best regards,
Official representative of Russian Federation,Deputy Minister of Trade and IndustryY. Slyusar
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
RE: FINAL Accident KNKT.12.05.09.04 Sukhoi 97004:
Collision with terrain - Mount Salak, West Java, Indonesia - 9 May 2012 Monday, December 24, 2012 07:42PM
From: Emmanuel DELBARRE" <emmanuel.delbarre@bea-fr.org>
To: <KNKT@dephub.go.id>, <permanence@bea-fr.org>, <johan.condette@bea-fr.org>, <tatangkurniadi@dephub.go.id>
Cc: <air.knkt@dephub.go.id>, "'Jean-Paul TROADEC'" <jean-paul.troadec@bea-fr.org>, 'François HOCHART' <hct@bea-fr.org>,
<johan.condette@bea-fr.o
Dear Mr Tatang Kurniadi and NTSC colleagues
I acknowledge receipt on your final report on the Sukhoi accident.
I wish to thank you for taking into account the BEA comments.
We appreciate the good cooperation that has prevailed between our services throughout the
completion of this investigation.
Best regards
Emmanuel DELBARREEnquêteur technique -Département Investigation
Safety Investigator -Investigations Department
emmanuel.delbarre@bea-fr.orgT : + 33 1 49 92 78 47
BEABureau d’Enquêtes et d’Analysespour la Sécurité de l’Aviation civileZone Sud - Bâtiment 153200 rue de ParisAéroport du BourgetF – 93352 Le Bourget Cedexwww.bea.aero
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
Greetings,
Our congratulations on a well written report. The only comment we have is as follows,
from ACSS:
On page 44 the report states:
“If the TAWS was still operating it would trigger “Too Low Gear” warning. Absence of
the TAWS warning indicated that the TAWS has no longer operating.”
ACSS suggests simply deleting this sentence as it is not accurate.
When selecting TAWS inhibit, only the predictive alerting (TAWS) function is inhibited,
it does not inhibit the basic GPWS ‘Reactive’ alerting such as the too low gear alert.
Thank you for your attention, as always it is a pleasure to work with you.
Bill ENGLISH NTSB Office of Aviation Safety Major Investigations AS-10 Investigator in Charge U.S. Accredited Representative 490 L'Enfant Plaza SW
Washington, D.C., USA 20594
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
KOMITE NASIONAL KESELAMATAN TRANSPORTASI
NATIONAL TRANSPORTATION SAFETY COMMITTEE
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KOMITE NASIONAL KESELAMATAN TRANSPORTASINATIONAL TRANSPORTATION SAFETY COMMITTEE
Transportation Building 3rd floorJl. Medan Merdeka Timur No. 5, Jakarta - 10110 INDONESIA
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