KOMITE NASIONAL KESELAMATAN TRANSPORTASI NASIONAL KESELAMATAN TRANSPORTASI ... NASIONAL KESELAMATAN...

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  • KOMITE NASIONAL KESELAMATAN TRANSPORTASI REPUBLIC OF INDONESIA 2014

    FFIINNAALL KKNNKKTT..1133..0055..1133..0044

    KKOOMMIITTEE NNAASSIIOONNAALL KKEESSEELLAAMMAATTAANN TTRRAANNSSPPOORRTTAASSII

    PT. Nusantara Buana AirCasa 212-200; PK - TLG

    Sultan Babullah Airport; TernateRepublic of Indonesia

    10 May 2013

    Aircraft Accident Investigation Report

  • This final report was produced by the Komite Nasional Keselamatan Transportasi (KNKT) 3rd Floor Ministry of Transportation, Jalan Medan Merdeka Timur No. 5 Jakarta 10110, INDONESIA.

    The report is based upon the investigation carried out by the KNKT in accordance with Annex 13 to the Convention on International Civil Aviation Organization, the Indonesian Aviation Act (UU No. 1/2009) and Government Regulation (PP No. 62/2013).

    The final report consists of factual information collected until the final report published. This report includes analysis and conclusion.

    Readers are advised that the KNKT investigates for the sole purpose of enhancing aviation safety. Consequently, the KNKT reports are confined to matters of safety significance and may be misleading if used for any other purpose.

    As the KNKT 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 the KNKT as the source

    When the KNKT makes recommendations as a result of its investigations or research, safety is its primary consideration.

    However, the KNKT 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 KNKT reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability.

  • i

    TABLE OF CONTENTS TABLE OF CONTENTS ........................................................................................................ i

    TABLE OF FIGURES ......................................................................................................... iii

    ABBREVIATIONS AND DEFINITIONS .......................................................................... iv

    INTRODUCTION ................................................................................................................. vi

    1 Factual Information ........................................................................................................ 11.1 History of the Flight .............................................................................................. 1

    1.2 Injuries to Persons ................................................................................................. 2

    1.3 Damage to Aircraft ................................................................................................ 2

    1.4 Other Damage ........................................................................................................ 2

    1.5 Personnel Information ........................................................................................... 3

    1.5.1 Pilot in Command ..................................................................................... 3

    1.5.2 Second in Command ................................................................................ 3

    1.6 Aircraft Information .............................................................................................. 4

    1.6.1 General ..................................................................................................... 4

    1.6.2 Engines ..................................................................................................... 5

    1.6.3 Propellers .................................................................................................. 5

    1.6.4 Maintenance record .................................................................................. 5

    1.7 Meteorological Information ................................................................................... 9

    1.8 Aids to Navigation ................................................................................................. 9

    1.9 Communications .................................................................................................... 9

    1.10 Aerodrome Information ......................................................................................... 9

    1.11 Flight Recorders .................................................................................................. 10

    1.11.1 Cockpit Voice Recorder ...................................................................... 10

    1.12 Wreckage and Impact Information ...................................................................... 10

    1.12.1 The Left Propeller Hub ....................................................................... 10

    1.13 Medical and Pathological Information ................................................................ 11

    1.14 Fire ....................................................................................................................... 11

    1.15 Survival Aspects .................................................................................................. 11

    1.16 Tests and Research .............................................................................................. 12

    1.16.1 Observation on the Fail Part ................................................................ 12

    1.17 Organizational and Management Information ..................................................... 14

    1.17.1 Continues Airworthiness Maintenance Program ................................ 14

  • ii

    1.18 Additional Information ........................................................................................ 15

    1.18.1 Airworthiness Directive ...................................................................... 15

    1.18.2 Propeller Log Book ............................................................................. 16

    1.19 Useful or Effective Investigation Techniques ..................................................... 16

    2 ANALYSIS ..................................................................................................................... 172.1 Cause of Failure ................................................................................................... 17

    2.2 Aircraft Maintenance Records ............................................................................. 17

    2.3 Miss-interpretation of maintenance interval ........................................................ 17

    3 CONCLUSIONS ............................................................................................................ 193.1 Findings ............................................................................................................... 19

    3.2 Contributing Factors ............................................................................................ 19

    4 SAFETY ACTION ........................................................................................................ 204.1 The Nusantara Buana Air .................................................................................... 20

    4.2 Directorate airworthy and Aircraft Operation ..................................................... 20

    5 SAFETY RECOMMENDATIONS ............................................................................. 215.1 PT. Nusantara Buana Air ..................................................................................... 21

    5.2 Directorate General of Civil Aviation; c.q. Directorate of Airworthiness and Aircraft Operation ................................................................................................ 21

    6 APPENDICES................................................................................................................ 226.1 A sample of Propeller half rear hub inspection result ......................................... 22

    6.2 Airworthiness Directive ....................................................................................... 24

    6.3 Propeller Log Book ............................................................................................. 25

  • iii

    TABLE OF FIGURES Figure 1: Predicted flight track up to the detachment of propeller ......................................... 1

    Figure 2: The aircraft after incident ........................................................................................ 2

    Figure 3: Aircraft component status recorded based on flight hours ...................................... 6

    Figure 4: Aircraft flight & maintenance log on the 5 October 2012....................................... 6

    Figure 5: Aircraft flight & maintenance log on the 7 October 2012....................................... 7

    Figure 6: Aircraft flight & maintenance log on the 2 February 2013 ..................................... 8

    Figure 7: Aircraft flight & maintenance log on the 20 March 2013 ....................................... 8

    Figure 8: Aircraft flight & maintenance log on the 10 May 2013 .......................................... 9

    Figure 9: Remaining left propeller hub half attached at the propeller flange ....................... 10

    Figure 10: Detail of propeller assembly ................................................................................ 11

    Figure 11: Fatigue cracks: darker surface shows earlier crack development while the lighter surface shows cracks developed somewhat later ................................................... 12

    Figure 12: Fatigue cracks star