FINAL

KNKT 08.01.02.04

NATIONAL
TRANSPORTATION
SAFETY
COMMITTEE

Aircraft Accident Investigation Report

PT. Dirgantara Air Service

PK–VSE
Casa 212-200
En-route Tarakan – Long Apung
East Kalimantan
Republic of Indonesia

26 January 2008

NATIONAL TRANSPORTATION SAFETY COMMITTEE

MINISTRY OF TRANSPORTATION
REPUBLIC OF INDONESIA
2010
This Draft Final Accident Investigation Report was produced by the
National Transportation Safety Committee (NTSC), Karya Building
7th Floor Ministry of Transportation, Jalan Medan Merdeka Barat
No. 8 JKT 10110, Indonesia.
The report is based upon the investigation carried out by the NTSC
in accordance with Annex 13 to the Convention on International
Civil Aviation, Aviation Act (UU No.1/2009), and Government
Regulation (PP No. 3/2001).
Readers are advised that the NTSC investigates for the sole purpose
of enhancing aviation safety. Consequently, NTSC reports are
confined to matters of safety significance and may be misleading if
used for any other purpose.
As NTSC believes that safety information is of greatest value if it is
passed on for the use of others, readers are encouraged to copy or
reprint for further distribution, acknowledging NTSC as the source.

When the NTSC makes recommendations as a result of its

investigations or research, safety is its primary consideration.
However, the NTSC fully recognizes that the implementation
of recommendations arising from its investigations will in
some cases incur a cost to the industry.
Readers should note that the information in NTSC reports and
recommendations is provided to promote aviation safety. In
no case is it intended to imply blame or liability.
 TABLE OF CONTENT

TABLE OF CONTENT........................................................................................................I
TABLE OF FIGURES.......................................................................................................III
GLOSSARY OF ABBREVIATIONS ............................................................................... V
SYNOPSIS ............................................................................................................................ 1
1 FACTUAL DATA....................................................................................................... 3
1.1 History of the Flight .....................................................................................................3
1.2 Injuries to Persons ........................................................................................................4
1.3 Damage to Aircraft .......................................................................................................4
1.4 Other Damage...............................................................................................................4
1.5 Personnel Information ..................................................................................................4
1.5.1 Pilot in Command ....................................................................................................... 4
1.5.2 Copilot......................................................................................................................... 5
1.5.3 Engineer ...................................................................................................................... 5
1.6 Aircraft Information .....................................................................................................5
1.6.1 General ........................................................................................................................ 5
1.6.2 Engine Data................................................................................................................. 6
1.6.3 Propeller data .............................................................................................................. 6
1.6.4 Weight and balance ..................................................................................................... 6
1.6.5 Defects ........................................................................................................................ 7
1.7 Meteorological information ..........................................................................................7
1.8 Aids to Navigation........................................................................................................7
1.9 Communications...........................................................................................................7
1.10 Aerodrome Information ................................................................................................7
1.11 Flight Recorders ...........................................................................................................7
1.11.1 Flight Data Recorder ................................................................................................... 7
1.11.2 Cockpit Voice Recorder .............................................................................................. 8
1.11.3 Notable facts CVR ...................................................................................................... 8
1.12 Wreckage and Impact Information ...............................................................................8
1.13 Medical and Pathological Information .........................................................................9
1.14 Fire................................................................................................................................9
1.15 Survival Aspects ...........................................................................................................9
1.16 Tests and Research .......................................................................................................9
1.17 Organizational and Management Information..............................................................9

i
 1.17.1 P.T Dirgantara Air Service ..........................................................................................9
1.18 Additional information............................................................................................... 10
1.19 Useful or Effective Investigation Techniques............................................................ 10
2 ANALYSIS .................................................................................................................11
3 CONCLUSIONS........................................................................................................13
3.1 Findings...................................................................................................................... 13
3.2 Causes ........................................................................................................................ 13
4 SAFETY RECOMMENDATIONS..........................................................................15
4.1 Safety Actions............................................................................................................ 15
4.2 Recommendations...................................................................................................... 15
4.2.1 PT. Dirgantara Air Service ........................................................................................15

ii
 TABLE OF FIGURES

FIGURE 1: PK-VSE ACCIDENT SITE ............................................................................................................ 3 

FIGURE 2: ARROW SHOWS FIRST IMPACT WITH TREE......................................................................... 8 

iii
iv
 GLOSSARY OF ABBREVIATIONS

AD Airworthiness Directive
AFM Airplane Flight Manual
AGL Above Ground Level
ALAR Approach-and-landing Accident Reduction
AMSL Above Mean Sea Level
AOC Air Operator Certificate
ATC Air Traffic Control
ATPL Air Transport Pilot License
ATS Air Traffic Service
ATSB Australian Transport Safety Bureau
Avsec Aviation Security
BMG Badan Meterologi dan Geofisika
BOM Basic Operation Manual
°C Degrees Celsius
CAMP Continuous Airworthiness Maintenance Program
CASO Civil Aviation Safety Officer
CASR Civil Aviation Safety Regulation
CPL Commercial Pilot License
COM Company Operation Manual
CRM Cockpit Recourses Management
CSN Cycles Since New
CVR Cockpit Voice Recorder
DFDAU Digital Flight Data Acquisition Unit
DGCA Directorate General of Civil Aviation
DME Distance Measuring Equipment
EEPROM Electrically Erasable Programmable Read Only
Memory
EFIS Electronic Flight Instrument System
EGT Exhaust Gas Temperature
EIS Engine Indicating System
FL Flight Level
F/O First officer or Copilot
FDR Flight Data Recorder
FOQA Flight Operation Quality Assurance

v
GPWS Ground Proximity Warning System
hPa Hectopascals
ICAO International Civil Aviation Organization
IFR Instrument Flight Rules
IIC Investigator in Charge
ILS Instrument Landing System
Kg Kilogram(s)
Km Kilometer(s)
Kt Knots (NM/hour)
Mm Millimeter(s)
MTOW Maximum Take-off Weight
NM Nautical mile(s)
KNKT / Komite Nasional Keselamatan Transportasi / National
NTSC Transportation Safety Committee
PIC Pilot in Command
QFE Height above aerodrome elevation (or runway
threshold elevation) based on local station pressure
QNH Altitude above mean sea level based on local station
pressure
RESA Runway End Safety Area
RPM Revolution Per Minute
SCT Scattered
S/N Serial Number
SSCVR Solid State Cockpit Voice Recorder
SSFDR Solid State Flight Data Recorder
TS/RA Thunderstorm and rain
TAF Terminal Aerodrome Forecast
TSN Time Since New
TT/TD Ambient Temperature/Dew Point
TTIS Total Time in Service
UTC Coordinated Universal Time
VFR Visual Flight Rules
VMC Visual Meteorological Conditions

vi
SYNOPSIS
On 26 January 2008, a Casa 212-200 aircraft, registered PK-VSE, was being
operated by PT. Dirgantara Air Service as a cargo charter flight from Tarakan
Airport to Long Apung Airport. There were three persons on board; two pilots
and one aircraft maintenance engineer/load master. The aircraft was certified
as being airworthy prior to departure.

The aircraft departed from Tarakan at 0011 UTC (08:11 local time), and the
estimated time arrival at Long Apung was 0136. At 0411 the pilot of another
aircraft received a distress signal and informed air traffic services at Tarakan.

Searchers subsequently found the aircraft wreckage at an elevation of 2,766

feet, about 3.4 NM from Long Apung Airport. The coordinates of the accident
site were 01° 39.483′ S and 115° 00.265′ E near Lidung Payau Village,
Malinau, East Kalimantan. The accident site was on the left downwind leg of
the runway 35 circuit.

Witnesses reported that at the time of the occurrence the downwind leg of the
circuit for Runway 35 at Long Apung Airport was obscured by low cloud.

The copilot twice warned the PIC “be careful sir, there is a hill”. It is likely
that the pilots were unable to keep the runway in sight during the maneuvering
on downwind for runway 35.

The investigation determined that it is likely that the pilots did not maintain
visual flight procedures, and flew the aircraft into instrument meteorological
conditions prior to colliding with the terrain.

As a result of this investigation, the National Transportation Safety Committee

issued recommendations to address safety issues identified in this report.
Specifically with respect to the operators pilot training and checking, to ensure
that it covers the use of the Flight Safety Foundation (FSF) (or similar)
Approach-and-landing Accident Reduction (ALAR) and Controlled Flight Into
Terrain (CFIT) awareness training material.

1
2
1 FACTUAL DATA
1.1 HISTORY OF THE FLIGHT
On 26 January 2008, a Casa 212-200 aircraft, registered PK-VSE, was
being operated by PT. Dirgantara Air Service as a cargo charter flight
from Tarakan Airport to Long Apung Airport. There were 3 persons on
board; two pilots and one aircraft maintenance engineer/load master. The
aircraft was certified as being airworthy prior to departure.

The aircraft departed from Tarakan at 0011 UTC1 (08:11 local time), and
the estimated time arrival at Long Apung was 0136. At 0411 the pilot of
another aircraft received a distress signal and informed air traffic
services at Tarakan.

Searchers subsequently found the aircraft wreckage at an elevation of

2,766 feet, about 3.4 NM from Long Apung Airport. The coordinates of
the accident site were 01° 39.483′ S and 115° 00.265′ E near Lidung
Payau Village, Malinau, East Kalimantan. The accident site was on the
left downwind leg of the runway 35 circuit.

Figure 1: PK-VSE accident site

1
The 24-hour clock in Coordinated Universal Time (UTC) is used in this report to describe the local
time as specific events occurred. Local time in the area of the accident, Centre Indonesia Standard
Time (Waktu Indonesia Tengah (WIT)) is UTC +8 hours.

3
1.2 INJURIES TO PERSONS
Table 1: Injuries to persons

Injuries Flight crew Passengers Total in Others

Aircraft
Fatal 3 - 3 -
Serious - - - -
Minor - - - Not applicable
Nil Injuries - Not applicable
TOTAL 3 - 3 -

The aircraft occupants were Indonesian citizens.

1.3 DAMAGE TO AIRCRAFT

The aircraft was destroyed by impact forces. The right wing root was
substantially damaged by a post-impact fire.

1.4 OTHER DAMAGE

The accident occurred in the forest and some trees were damaged.

1.5 PERSONNEL INFORMATION

1.5.1 Pilot in Command
Age : 58 years
Gender : Male
Type of licence : Airline Transport Pilot License
Valid to : 30 April 2008
Rating : Casa 212-100 & 200, BN 2A
Total flying time : 21,019 hours 40 minutes
Total on this type : 14,234 hours 56 minutes
Total last 90 days : 146 hours 22 minutes
Total on type last 30 days : 56 hours 43 minutes
Total on type last 7 days : Not provided by the operator
Total on the type last 24 hours : 1 hours 25 minutes
Last proficiency check : Not provided
Medical class : Class one
Last medical examination : 22 October 2007

4
1.5.2 Copilot
Age : 50 years
Gender : Male
Type of licence : Commercial Pilot License
Valid to : 31 March 2008
Rating : Casa 212-100 & 200
Total flying time : 16,849 hours 46 minutes
Total on this type : 16,849 hours 15 minutes
Total last 90 days : 189 hours 35 minutes
Total last 30 days : 56 hours 43 minutes
Total on type last 7 days : Not provided
Total on the type last 24 hours : 1 hours 25 minutes
Last proficiency check : Not provided by the operator
Medical class : Class one
Last medical examination : 31 March 2007

1.5.3 Engineer
Age : 43 years
Gender : Male
Type of licence : Aircraft Maintenance Engineer
License
Valid to : 26 August 2008

1.6 AIRCRAFT INFORMATION

1.6.1 General
Aircraft manufacturer : Casa / Indonesia Aerospace
Model : Casa 212-200 CC4
Serial number : 092N/412
Date of manufacture : 30 July 1993
Nationality and registration mark : Indonesia, PK-VSE
Name of the owner : PT. Dirgantara Air Service
Name of the operator : PT. Dirgantara Air Service
Certificate of Airworthiness Valid to : 20 May 2008
Certificate of Registration Valid to : 10 June 2008
Total flying hours : 11,750 hours 53 minutes
Total cycle : 13,749 cycles
Last Inspection (A3 on 16 January 2008) : 11,693 hours

5
 The aircraft was maintained in accordance with the PT. DAS Continuous
Airworthiness Maintenance Program, and the aircraft was certified as
being airworthy prior to departure.

1.6.2 Engine Data

Engine type : Turbo Propeller
Manufacturer : Casa 212-200 CC4
Type/Model : TPE 331-10R-512 C
Engine number 1 (Left)
Serial number : P-37410 C
Time since new : 8,988 hours 47 minutes
Cycles since new : 8,926 cycles
Time since overhaul : 6,252 hours
Time between overhaul : 7,000 hours
Engine number 2 (Right)
Serial number : P-37436 C
Time since new : 6,510 hours
Cycles since new : 4,881hours
Time since overhaul : 3,664 hours
Time between overhaul : 5,400 hours

1.6.3 Propeller data

Propeller type : Variable Pitch Prop
Manufacturer : Dowty Propeller
Type/Model : P/N R334/4/82/F/13
Propeller number 1 (Left)
Serial number : DRG-1377/90
Time since new : 21 hours 38 minutes
Time since overhaul : 21 hours 38 minutes
Time between overhaul : 5,000 hours
Propeller number 2 (Right)
Serial number : DRG-1458/90
Time since new : 2,525 hours 40 minutes
Cycles since new : 2,525 hours 40 minutes
Time between overhaul : 5,000 hours

1.6.4 Weight and balance

The load sheet indicated that the aircraft was loaded within weight and
balance limits at the time of the departure.

6
1.6.5 Defects

The maintenance documents showed no evidence of mechanical defects

that could have contributed to the accident.

1.7 METEOROLOGICAL INFORMATION

The weather forecast for Long Apung at 0000 was wind calm, visibility
1500 meters, and cloud 6 octas at 1,000 feet.

Witnesses at the airport reported that at the time of the occurrence the
downwind leg of the circuit for Runway 35 at Long Apung Airport was
obscured by low cloud.

1.8 AIDS TO NAVIGATION

The flight was being conducted under the visual flight rules. There were
no ground-based navigation aids for the route.

1.9 COMMUNICATIONS
The pilot broadcast his flight departure and estimated arrival time on the
very high frequency channel for the area. There was no communication
equipment at Long Apung Airport.

1.10 AERODROME INFORMATION

Airport Name Long Apung
Airport Identification WALP
Coordinate 01° 03.0′ S and 114° 58.0′ E
Elevation 2,010 feet
Airport Operator Directorate General Civil Aviation
Runway Direction 17/35
Runway Length 900 meters
Runway Width 23 meters
Surface Asphalt

1.11 FLIGHT RECORDERS

1.11.1 Flight Data Recorder

The aircraft was not fitted with a flight data recorder (FDR) nor was one
required by current Indonesian regulations.

7
1.11.2 Cockpit Voice Recorder
Manufacturer : Fairchild Aviation Recorder,
Model : A100A
Serial number : 5301

The CVR contained good quality data that was transcribed by NTSC
investigators.

1.11.3 Notable facts CVR

From the conversation between the PIC and the copilot, there was no
sign of an aircraft abnormality.

Seven seconds before the final impact, the copilot warned the PIC, “be
careful sir, there is a hill”. At 30:18 CVR time, the copilot again warned
the PIC about the hill.

Six seconds later, the first impact sound and a shout were recorded.

This was followed a second later by an impact sound and the signal from
the Emergency Locator Transmitter were recorded.

1.12 WRECKAGE AND IMPACT INFORMATION

The aircraft impacted trees and the terrain and wreckage was confined to
the immediate accident site.

Figure 2: Arrow shows first impact with tree

8
1.13 MEDICAL AND PATHOLOGICAL INFORMATION
No medical or pathological investigations were conducted on the flight
crew.

1.14 FIRE
There was no evidence of pre-impact fire. A post-accident fuel-fed fire
substantially damaged the right wing root area. No rescue fire fighting
services attended the accident site nor were they available in the remote
location.

1.15 SURVIVAL ASPECTS

The accident was not survivable.

1.16 TESTS AND RESEARCH

None required.

1.17 ORGANIZATIONAL AND MANAGEMENT

INFORMATION
1.17.1 P.T Dirgantara Air Service

Aircraft Owner : PT. Dirgantara Air Service

Aircraft Operator : P.T Dirgantara Air Service

Halim Perdanakusuma Airport, 2nd Floor,
Jakarta, Indonesia

Aircraft Operator Certificate number: AOC/135-014

9
1.18 ADDITIONAL INFORMATION
The cargo moved during the impact. Investigators found that the cargo
was not adequately restrained.

The bulb (filament) examination of the instrument panel warning/caution

lights revealed no evidence of in-flight fire.

Bulb Analysis Instrument Panel

Generator Left Generator Fuel Level Left Fuel Level Pitot Heat Left Pitot Heat Righ SRL & Start Inverter No 1 Battery Temp Unsafe Door
Right Tank Righ Tank CMPTR Right No 1

® ⊗ ® ® ⊗ ⊗ ⊗ ⊗ ⊗ ® ⊗ ⊗ ® ⊗ ® ⊗ ® ⊗ ® ®
Oil Pressure Oil Pressure Left Fuel Right Fuel Windshield Windshield SRL & Start Inverter No 2 Battery Over Over speed
Left Right Shutoff Valve Shutoff Valve Heat Left Heat Right CMPTR Left Timp

® ® ® ® ⊗ ⊗ ⊗ ⊗ ® ⊗ ® ⊗ ⊗ ® ® ⊗ ® ® ® ⊗
Chip Detector Chip Detector Fuel Pressure Fuel Pressure Air Intake Heat Air Intake Heat Bagage Compt Aux Inverter Battery Temp Battery Temp
Left Right Left Engine Right Engine Left Right Smoke No 2 No 3

⊗ ® ® ® ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ⊗ ® ® ® ® ® ⊗ ⊗
LH FIRE RH FIRE

⊗ ⊗ ® ® ⊗ ⊗

Cover Ok Cover Pecah Glass Envelope Ok Glass Envelope Pecah

® → Filamen Ok ⊗ → Filamen Putus

1.19 USEFUL OR EFFECTIVE INVESTIGATION

TECHNIQUES
The investigation was conducted in accordance with NTSC-approved
policies and procedures, and in accordance with the Standards and
Recommended Practices of Annex 13 to the Chicago Convention.

10
2 ANALYSIS
At the time of the occurrence, it was reported that the left downwind leg
of the circuit for runway 35 at Long Apung Airport was obscured by low
cloud.

The copilot twice warned the PIC “be careful sir, there is a hill”. It is
likely that the pilots were unable to keep the runway in sight during the
maneuvering on downwind for runway 35.

The investigation determined that it is likely that the pilots did not
maintain visual flight procedures, and flew the aircraft into instrument
meteorological conditions prior to colliding with the terrain.

11
12
3 CONCLUSIONS
3.1 FINDINGS
• The aircraft was certified as being airworthy prior to departure.

• All crew members held appropriate and valid flight crew licenses.

• The pilots continued flight into instrument meteorological conditions.

• The aircraft impacted terrain in controlled flight.

• The cargo was not adequately restrained.

3.2 CAUSES
The crew did not appear to have awareness of the aircraft’s proximity
with terrain until impact with terrain was imminent.

The pilot attempted to continue the flight in instrument meteorological

conditions, below the lowest safe altitude.

13
14
4 SAFETY RECOMMENDATIONS
4.1 SAFETY ACTIONS
At the time of finalising this report, the National Transportation Safety
Committee had not been informed of any safety action taken.

4.2 RECOMMENDATIONS
As a result of the investigation into this accident, the National
Transportation Safety Committee made the following recommendations.

4.2.1 PT. Dirgantara Air Service

The National Transportation Safety Committee recommends that PT.

Dirgantara Air Service should review its pilot training and checking to
ensure that it covers the use of the Flight Safety Foundation (FSF) (or
similar) Approach-and-landing Accident Reduction (ALAR) and
Controlled Flight Into Terrain (CFIT) awareness training material.

• The ALAR and CFIT awareness modules should be included in

PT. Dirgantara Air Service recurrency training programs, and
conduct initial ALAR and CFIT training for flight crew
members who have not yet completed such training.

15