Lessons Learn of the Sukhoi RRJ-95B Investigation Mount Salak ...

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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• 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



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





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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





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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





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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





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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





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Emergency Locator Transmitter (ELT) 406

Antenna connection



The Black Box

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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



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



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" <[email protected]>

To: <[email protected]>, <[email protected]>, <[email protected]>, <[email protected]>

Cc: <[email protected]>, "'Jean-Paul TROADEC'" <[email protected]>, 'François HOCHART' <[email protected]>,

<[email protected]

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

[email protected] : + 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



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





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KOMITE NASIONAL KESELAMATAN TRANSPORTASINATIONAL TRANSPORTATION SAFETY COMMITTEE

Transportation Building 3rd floorJl. Medan Merdeka Timur No. 5, Jakarta - 10110 INDONESIA

Telp. (021) 384 7601, 3517606 ; Fax (021) 351 7606Website : http://www.dephub.go.id/knkt

E-mail : [email protected]

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