TAHUN 2007 - 2019 (Data s.d Desember 2020) - Komite ...

KNKT.15.02.04.04 - PT.

Garuda Indonesia

ATR 72‐600; PK‐GAG

Lombok International

Airport

Republic of Indonesia

03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016Directorate General

of Civil Aviation04 R 2016 4 1

Refer to analysis chapter 2.1, 2.2 and 2.3 of this report, the KNKT recommends

that DGCA should oversight the implementation of recommendation

addressed to the air

operator, to ensure the effectiveness ofthe operators safety improvement and

to facilitate the recommendation addressed to airport operator.

OPEN 9-Mar-2017 NIL PENGAWASAN

KNKT.15.02.04.04 - PT.

Garuda Indonesia



Airport


03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 1The handling of the aircraft was contrary to the wind condition. The KNKT

recommends that the operator shall emphasized the crosswind handling. OPEN 27-Jan 2020 9-Mar-2017

Chief Pilot ATR has issued notice no. 03/15 and 04/15

date 11 February 2015 to all ATR

Flight Crew regarding “Safety Precaution regarding

event GA7040 at LOP” which contained

key points for a safe and successful crosswind landing.

ATURAN

KNKT.15.02.04.04 - PT.

Garuda Indonesia



Airport


03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 2

In the preliminary report of this investigation, KNKT issued recommendation

related to standard call out on final. In addition, investigation identified two

change over control of the flight at critical phase of flight without clear

statements. This condition may also extend to the other instructors within

the company. Therefore, KNKT recommends to review the policy of change

over control at critical altitude.

OPEN 27-Jan 2020 9-Mar-2017

VP Flight Operations has issued notice no. 04/15 date

on 9 February 2015 to all Flight Crew.

Chief Pilot ATR has issued notice no. 04/15 date 11

February 2015 to all ATR Flight Crew

regarding “Safety Alertness Regarding Critical Phase of

Flight” which instructed all PiC to

keep maintain situational awareness in all phase of

flight (Approach and Landing) with

follow procedures consistently at 500’ Agl PiC as Pilot

PENGAWASAN

KNKT.15.02.04.04 - PT.

Garuda Indonesia



Airport


03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016

Angkasa Pura I

Branch Office

Lombok

International Airport

04 B 2016 4 1

Refer to analysis chapter 2.3 of this report, the KNKT recommends that the

airport operator should improve the surfaces runway strip conditionto comply

with existing regulation.

OPEN 9-Mar-2017 NIL PRASARANA

KNKT.15.03.06.04 - PT.

DERAYA AIR - British

Aerospace Bae ATP ;

PK-DGB;

Wamena Airport, Papua

4 Maret 2015

PK-DGB 4-Mar 2015 Interim Report 11-Dec 2017 Deraya Air 04 O 2017 6 1

The aircraft landed and skid to the right, then re-entered the runway, KNKT

recommends to review the flight crew training related to wet or slippery

runway landing technique.

CLOSED 13-Mar 2018 11-Mar-2018Review & Class Discussion Wet/Slippery Runway

Landing TechniquePENGAWASAN

KNKT.15.03.06.04 - PT.

DERAYA AIR - British

Aerospace Bae ATP ;

PK-DGB;


4 Maret 2015

PK-DGB 4-Mar 2015 Interim Report 11-Dec 2017 Deraya Air 04 O 2017 6 2

During the approach, the visibility was reported 2-3 km and continuous heavy

rain, KNKT recommends to ensure the pilot to comply to the minimum

weather condition prior to initiate the approach.

CLOSED 13-Mar 2018 11-Mar-2018Ensure compliance to Weather Minimum prior to

initiate the approach.PENGAWASAN

KNKT.15.03.07.04 - PT.

Elang Nusantara Air -

Thrush S2R-T34; PK-ELN

Airstrip Tajur Baras,

Waringin Timur,

Kalimantan Tengah 13

Maret 2015

PK-ELN 13-Mar 2015 Final Report 9-Dec 2016 Elang Nusantara Air 04 O

Agar melakukan evaluasi program Training dan implementasinya bagi

instruktur pilot yang akan mejalankan fungsinya sesuai kriteria pada approved

Agriculture Manual terkait kemampuan teknis sesuai dengan rating atau tipe

pesawat yang dioperasikan.


KNKT.15.03.07.04 - PT.




Waringin Timur,


Maret 2015

PK-ELN 13-Mar 2015 Final Report 9-Dec 2016 Elang Nusantara Air 04 O

Mengisi posisi Chief Pilot untuk penerbangan agriculture dan tidak melakukan

operasi penerbangan agriculture sementara waktu sebelum posisi Chief Pilot

tersebut terisi.

OPEN 9-Mar-2017 NIL ATURAN

KNKT.15.03.07.04 - PT.




Waringin Timur,


Maret 2015

PK-ELN 13-Mar 2015 Final Report 9-Dec 2016Directorate General

of Civil Aviation04 R

Memonitor dan mengawasi pelaksanaan rekomendasi KNKT pada butir 7.1. (a)

dan (b) bagi PT. Elang Nusantara Air dan operator sejenis lainnyaOPEN 9-Mar-2017 NIL PENGAWASAN

KNKT.15.03.07.04 - PT.




Waringin Timur,


Maret 2015

PK-ELN 13-Mar 2015 Final Report 9-Dec 2016Directorate General

of Civil Aviation04 R

Melakukan review terkait pengoperasian pesawat jenis agriculture dengan

sertifikasi AOC 135.OPEN 9-Mar-2017 NIL PENGAWASAN

2

TANGGAPAN (RESPONSE)

STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)

TAHUN 2007 - 2019 (Data s.d Desember 2020)

NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI

(RECOMMENDATION NUMBER)

BATAS

WAKTU (DUE

DATE)

REKOMENDASI (RECOMMENDATION) STATUS

1

TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL

DIKELUARKAN (DATE OF

ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

3

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-GAG Final Report.pdf











NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.03.08.04 - PT.

Hevilift Aviation

Indonesia

Sikorsky S76 C+

Helicopter; PK-FUP

Delta Mahakam river,

East Kalimantan


21 March 2015

PK-FUP 21-Mar 2015 Preliminary Report 5-May 2015Directorate General


To ensure the implementation of safety action taken by Hevilift Aviation

Indonesia. OPEN 3-Aug-2015 NIL PENGAWASAN

KNKT.15.03.08.04 - PT.

Hevilift Aviation

Indonesia

Sikorsky S76 C+

Helicopter; PK-FUP

Delta Mahakam river,

East Kalimantan


21 March 2015

PK-FUP 21-Mar 2015 Preliminary Report 5-May 2015Directorate General


To review the others Sikorsky similar operation’s Operator related to the

training and the restriction of automation usage.OPEN 3-Aug-2015 NIL PENGAWASAN

KNKT.15.06.13.04 - PT.

Garuda Indonesia

Boeing 737‐800; PK‐GFA

Sultan Hasanuddin


Makassar

South Sulawesi


2 June 2015

PK-GFA 2-Jun 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 7 1To review the pilot training on meteorology training related to cumulonimbus

development and its effects. CLOSED 5-Jan 2017 9-Mar-2017

submit Briefing Guides technical TR/PC II year 2015, to

include “adverse weather/ windshear”PENGAWASAN

KNKT.15.06.13.04 - PT.

Garuda Indonesia


Sultan Hasanuddin


Makassar

South Sulawesi


2 June 2015

PK-GFA 2-Jun 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 8 2To emphasis all pilot to perform go around when a safe landing cannot be

made. CLOSED 5-Jan 2017 9-Mar-2017

1. Publish Notice to Flight Crew no. 021/15 date 6

June 2015 regarding “Situational awareness during

approach and landing”, such as during if there is any

runway changes, current weather condition, and if

there is any doubt, or the approach is not stabilized, or

the visibility drops rapidly to below minima, Flight Crew

do not hesitate to make a go around and/or rejected

landing. 2.

ublish Notice to Flight Crew no. 036/15 date 5 October

2015 regarding “Recommendation for landing RWY13

and 31 Sultan Hasanudin Airport/ WAAA” in order to

strictly follow the stabilized approach criteria and if the

criteria does not meet, make go around. In this notice,

also stated that during moderate and heavy rain, the

landing on RWY13 and 31 UPG is strongly not

recommended due to braking action is poor.

PENGAWASAN

KNKT.15.06.13.04 - PT.

Garuda Indonesia


Sultan Hasanuddin


Makassar

South Sulawesi


2 June 2015

PK-GFA 2-Jun 2015 Final Report 9-Dec 2016 AirNav Indonesia 04 A 2016 9 1To provide all controllers with meteorology training that includes the

understanding of cumulonimbus and windshear. OPEN 9-Mar-2017 NIL ATURAN

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015

PK-KIG 12-Aug 2015 Final Report 20-Jun 2016Directorate General


To include Controlled Flight into Terrain (CFIT) and Approach and Landing

Accident Reduction (ALAR) as a required training component in the CASR Part

135.

OPEN 18-Sep-2016 NIL ATURAN

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015



The information of runway elevation of Ninia in ALA did not represent the

actual elevation. KNKT recommends reviewing the ALA to ensure the

information contents are valid.

CLOSED 27-Mar 2018 18-Sep-2016

DBU akan mengarahkan agar penyelenggara Bandara

Ninia untuk mengajukan permohonan kepada

Direktorat Navigasi Penerbangan untuk pengukuran

elevasi runway.

PENGAWASAN

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015



To provide a regulation which requires pilot to be trained for flight with

unreliable airspeed.OPEN 18-Sep-2016 NIL ATURAN

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015

PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 40 1 To ensure pilot familiarization in conducting a flight to airport or airstrip. OPEN 18-Sep-2016 NIL PENGAWASAN

4

5

6

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary Report PK-FUP.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary Report PK-FUP.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-GFA Final Report.pdf



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/Final Report PK-KIG.pdf







NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015

PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 41 1 To provide pilot training in decision making especially in abnormal condition. OPEN 18-Sep-2016 NIL PENGAWASAN

KNKT.15.08.16.04 - PT.

Komala Indonesia

PAC-750XL; PK-KIG

Ninia Airstrip,

Yakuhimo, Papua


12 August 2015

PK-KIG 12-Aug 2015 Final Report 20-Jun 2016 Komala Indonesia 04 O 2016 42 1To conduct proper risk assessment including document preparation for

additional fleetOPEN 18-Sep-2016 NIL PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Preliminary Report 16-Sep 2015Directorate General


To ensure that the recommendations addressed to the air operator are well

implemented.OPEN 15-Dec-2015 NIL PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 27-Dec 2017Directorate General

of Civil AviationR

The investigation could not find any regulation required for training of any

addition or system modification which affect to the aircraft operation. KNKT

recommends to develop regulation requirement for training of any additional

or modification to equipment that affected to safety of aircraft operations.


KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015



The information for Oksibil published in AIP volume IV (Aerodrome for Light

Aircraft/ALA) did not include approach guidance. The operator issued visual

guidance of circling approach runway 11 for internal use. KNKT recommends

to publish the visual route guidance for airport without instrument approach

procedure.

CLOSED 27-Mar 2018 27-Mar-2018

Ditnavpen akan menawarkan pada Operator

penerbangan yang terbang pada rute tersebut dapat

menyampaikan draft Visual Guidance kepada

Ditnavpen/Perum LPPNPI unutk pembahasan lebih

lanjut.

ATURAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015



PBN offers a number of advantages over the sensor-specific method of

developing airspace and obstacle clearance criteria. KNKT recommends to

consider the application of Performance Based Navigation (PBN) approach for

compatible aircraft to fly in area with ground-based navigation system

implementation is limited.


RNP Approach belum dapat diimplementasikan karena

Terrain dan area yang sempit. Ditnavpen telah

menawarkan proyek ini pada TAR untuk PBN, namun

belum ada informasi lebih lanjut.

ATURAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015



There was no information related to the status of ZX NDB published on

NOTAM prior to the accident. KNKT recommends to ensure aeronautical

information for air navigation is updated in accordance with the current

condition, including the serviceability of the navigation aids.


Berdasarkan Notam C1226/16 Kondisi NDB Un-

Serviceable mulai 12 Maret 2016 hingga 1 April 2016.

Berdasarkan Notam C1483/16 Kondisi NDB beroperasi

normal mulai 24 Maret 2016. DNP telah

melakukan audit keselamatan penyelenggara navigasi

penerbangan pada Perum LPPNPI cabang Oksibil.

PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015


of Civil AviationR

EGPWS has worldwide terrain coverage in low resolution terrain data including

several airports with significant traffic movements. The Oksibil Airport was not

provided with the high-resolution terrain data in this database version. KNKT

recommends to coordinate with the manufacturer to provide several airports

in Indonesia with EGPWS high resolution terrain database.

OPEN 27-Mar-2018 NIL PRASARANA

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Airnav Indonesia 4 A 2015 17 3

There was no information related to the status of ZX NDB published on

NOTAM prior to the accident. KNKT recommends to ensure the status of the

navigation aids disseminates to the air navigation user in timely manner.

CLOSED 26-Feb 2018 27-Mar-2018

Memberikan informasi melalui NOTAM perihal NDB ZX Oksibil

sebagai berikut: (C1226/16 NOTAMN Q)

WAFF/QNBAS/IV/BO/AE/000/999/0450S14026E025 A) WAJO

B)1603120249 C)16049107000 E)NDB ZX 342KHZ

U/S DUE TO TECHNICAL REASON

PENGAWASAN

7

6



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2015 17 PK-YRN Final Report.pdf









NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Airnav Indonesia 4 A 2015 17 4

The flight plan form was filed with intended to fly under instrument flight rule

(IFR), at flight level 155, with route from Sentani to MELAM via airways W66

then to Oksibil. The MORA of W66 between Sentani to Oksibil was 18,500

feet. KNKT recommends to ensure filing the flight plan and flight execution is

accordance with the regulation.

CLOSED 26-Feb 2018 27-Mar-2018

Melaksanakan perbaikan dalam rangka peningkatan pelayanan

navigasi penerbangan meliputi : -

Pengusulan Penerbitan AIP Indonesia (Vol III) -

Mengikuti Indonesia PBN : ATR/Navblue Coorporation project -

Optimalisasi pemberian informasi oleh unit terkait melalui AIP

Indonesia (Vol IV)

PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 16-Sep 2015 Trigana Air Services 04 O 2015 17 1

To emphasis the flight crew to comply with the company procedures such as

crew briefing, checklist reading, approach procedure and visual flight rules

(VFR) minima and provide monitoring system.

OPEN 15-Dec-2015 NIL PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 16-Sep 2015 Trigana Air Services 04 O 2015 17 2To ensure the maintenance data record up date includes the installed

component.OPEN 15-Dec-2015 NIL PENGAWASAN

KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Trigana Air Services O

The visual approach guidance contained incorrect information of terrain (MSA)

and considered not easy to fly. KNKT recommends that approach guidance

shall be reviewed to ensure contain correct information and easy to fly to

minimise the pilot workload.


KNKT.15.08.17.04 - PT.

Trigana Air Service

ATR 42-300; PK-YRN

Near Oksibil, Papua


16 August 2015

PK-YRN 16-Aug 2015 Final Report 27-Dec 2017 Trigana Air Services O

The statement in the ATR SB number ATR42-34-0152 required the operator to

communicate to the manufacture related to the modification. KNKT

recommends that any modification to the aircraft especially when the

modification was related to aircraft safety, shall be communicated to the

manufacture and/or DGCA.


8

KNKT.15.08.18.04 - PT.

Garuda Indonesia

Airbus 330-200; PK-GPO

Inflight from Melbourne

to Jakarta

22 August 2015

PK-GPO 22-Aug 2015 Final Report 5-Dec 2016Directorate General


To enforce the development of cabin crew procedures by the operators to

adequately handle the dry ice on board the aircraft.OPEN 5-Mar-2017 NIL ATURAN

KNKT.15.08.20.04 - PT.

Cardig - Air

Boeing 737-300 F; Reg.

PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016Directorate General


To ensure the establishment and maintenance of flight data analysis program

as part of aircraft operator safety management system as stated in Civil

Aviation Safety Regulation part 121.65 (c).

OPEN 13-Sep-2016 NIL ATURAN

KNKT.15.08.20.04 - PT.

Cardig - Air


PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Cardig Air 04 O 2016 45 1 To improve the windshear training to ensure appropriate pilot respond. CLOSED 1-Feb 2018 13-Sep-2016

Pelaksanaan Windshear Training sesuai surat EVP.

Operations & COO PT. Cardig Air kepada Ketua

KNKT No. 2096/CADKNKT/ COO/V/16 tanggal 16 Mei

2016.

PENGAWASAN

KNKT.15.08.20.04 - PT.

Cardig - Air


PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Airnav Indonesia 04 A 2016 46 1To improve the knowledge of air traffic controller related to the windshear to

be able to provide useful information for flight operation.CLOSED 19-Sep 2016 13-Sep-2016

- Issued notice number

13.02.02/00/LPPNPI/05/2016/141 regarding the

improvement of ATC awareness during extreme bad

weather and clear air turbulence.

- Conducted safety awareness workshop and refreshing

course.

PENGAWASAN

7

9






http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2015 PK-GPO Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/Final Report PK-BBY.pdf






NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.08.20.04 - PT.

Cardig - Air


PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 47 1 To develop an aerodrome maintenance programme. OPEN 13-Sep-2016 NIL PRASARANA

KNKT.15.08.20.04 - PT.

Cardig - Air


PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 48 1 To review and improve the runway inspection system. OPEN 13-Sep-2016 NIL PENGAWASAN

KNKT.15.08.20.04 - PT.

Cardig - Air


PK-BBY

Wamena Airport


28 August 2015

PK-BBY 28-Aug 2015 Final Report 15-Jun 2016 Wamena Airport 04 B 2016 49 1 To install VASI on the runway 15. OPEN 13-Sep-2016 NIL PRASARANA

KNKT.15.10.21.04 - PT.

Aviastar Mandiri

DHC-6 Twin Otter; PK-

BRM

at coordinate 3° 25'

52.80" S, 120° 4' 12.10"

E

District of Luwu, South

Sulawesi


2 October 2015

PK-BRM 2-Oct 2015 Final Report 9-Dec 2016Directorate General


To emphasize the continuity of oversight program to ensure the installed

EGPWS/TAWS functioning properly.OPEN 9-Mar-2017 NIL PENGAWASAN

KNKT.15.10.21.04 - PT.

Aviastar Mandiri


BRM


52.80" S, 120° 4' 12.10"

E


Sulawesi


2 October 2015

PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 64 1To evaluate the effectiveness of the CRM training and ensuring the correct

pilot implementationCLOSED 28-Feb 2018 9-Mar-2017

PT. Aviastar Mandiri has conducted training CRM for all

Pilots and make Notice to Pilot that pilot must do

briefing before flight as implementation.

PENGAWASAN

KNKT.15.10.21.04 - PT.

Aviastar Mandiri


BRM


52.80" S, 120° 4' 12.10"

E


Sulawesi


2 October 2015

PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 65 2To ensure all pilots are appropriately trained on the operation and testing of

the EGPWS/TAWS systems.CLOSED 28-Feb 2018 9-Mar-2017

PT. Aviastar Mandiri has conducted Training for the

operation (Pilot) and Technic Division and testing of

the EGPWS/TAWS System.

PENGAWASAN

KNKT.15.10.21.04 - PT.

Aviastar Mandiri


BRM


52.80" S, 120° 4' 12.10"

E


Sulawesi


2 October 2015

PK-BRM 2-Oct 2015 Final Report 9-Dec 2016 Aviastar Mandiri 04 O 2016 66 3To ensure EGPWS/TAWS operational test procedure is incorporated into the

Operator’s Standard Operating Procedures (SOP) and pre‐flight checklists.CLOSED 28-Feb 2018 9-Mar-2017

PT. Aviastar Mandiri make Standard Operating

Procedure (SOP) for Responding to Alert TAWS and has

in state in Pre Flight Checklist (Cockpit Preparation)

ATURAN

KNKT.15.10.22.04 - PT.

Penerbangan Angkasa

Semesta

Eurocopter EC130 B4;

PK-BKA

Toba Lake, North

Sumatera


11 October 2015

PK-BKA 11-Oct 2015 Final Report 16-May 2016Penerbangan

Angkasa Semesta04 O 2016 32 1

To ensure the survival equipment is available on the aircraft suitable for area

operation and properly useCLOSED 23-Feb 2018 14-Aug-2016

OM Chapter 8.26 (Flight Overwater), OM Chapter 9.2.6

(Passeger Handling), OM Chapter 3.4.3 (Flight

Following and Flight Watch Facilities), Notice to Crew

No. PAS/NOT/IV/2016 (Emergency Equipment Check)

SARANA

KNKT.15.10.22.04 PT.

Penerbangan Angkasa

Semesta


PK-BKA

Toba Lake, North

Sumatera


11 October 2015

PK-BKA 11-Oct 2015 Final Report 16-May 2016Penerbangan

Angkasa Semesta04 O 2016 58 1 To conduct passenger safety briefing prior to every flight CLOSED 23-Feb 2018 14-Aug-2016

OM Chapter 9.2.2 (Passenger Briefing Procedure),

Safety Instruction Card.PENGAWASAN

KNKT.15.10.22.04 PT.

Penerbangan Angkasa

Semesta


PK-BKA

Toba Lake, North

Sumatera


11 October 2015

PK-BKA 11-Oct 2015 Final Report 16-May 2016Directorate General


To consider the regulation of using emergency equipment such as personal or

portable Emergency Locator Transmitter for personal in aircraft operated in

inhabitant terrain and offshore.

OPEN 14-Aug-2016 NIL ATURAN

9

10

11




http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-BRM Final Report.pdf




http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-BKA Final Report (ISBN).pdf






NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.10.21.04 - PT.

Aviastar Mandiri


BRM


52.80" S, 120° 4' 12.10"

E


Sulawesi


2 October 2015

PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 34 1 To consider instrument flight training for search and rescue pilots. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN

KNKT.15.10.21.04 - PT.

Aviastar Mandiri


BRM


52.80" S, 120° 4' 12.10"

E


Sulawesi

PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 35 1 To consider using drone or unmanned aerial vehicle for air search operation. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN

KNKT.15.10.24.04 - PT.

Asian One Air

Tecnam P2006T Aircraft;

PK-LTK

Nusawiru Airport

Pangandaran,

Jawa Barat

20 October 2015

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 Asian One Air 04 O 2016 10 1To improve the pilot crew resource management that may refer to the FAA

safety bulletinCLOSED 20-Feb 2018 24-Nov-2016

COM replaced by OM (OM part D 1.3.1 "Crew Resouce

Management")PENGAWASAN

KNKT.15.10.24.04 - PT.

Asian One Air


PK-LTK

Nusawiru Airport

Pangandaran,

Jawa Barat

20 October 2015

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 Asian One Air 04 O 2016 11 1

To improve the quality system operation to achieve requirements of Indonesia

regulations for the internal and other organization supporting Asian One Air

operation refer to CASR 135.85.

CLOSED 20-Feb 2018 24-Nov-2016 Operation facility inspection and aircraft inspection PENGAWASAN

KNKT.15.10.24.04 - PT.

Asian One Air


PK-LTK

Nusawiru Airport

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016 Asian One Air 04 O 2016 12 1

To improve the quality system of aircraft airworthiness to a achieve

requirements of CASR 135.85; CASR 135.363 and CASR 135.373 for the

internal and other organization supporting Asian One Air.

CLOSED 20-Feb 2018 24-Nov-2016MOU PT. Asian One Air and PT. MS Tech No.AOA

061/EDZA1A/N III/2017PENGAWASAN

KNKT.15.10.24.04 - PT.

Asian One Air


PK-LTK

Nusawiru Airport

Pangandaran,

Jawa Barat

20 October 2015

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016Mulya Sejahtera

Technology04 MO 2016 13 1

To improve the quality maintenance system to achieve requirements of CASR

43.15; CASR 145.205 and CASR 145.211CLOSED 24-Nov-2016

Melaksanakan beberapa training kepada para

Inspektur/Engineer PT.Mulya Sejahtera, yaitu : Basic

Inspector, Basic Supervisor, Potential Hazard, Human

Factor Recurrent. Dan Melaksanakan improvement

terhadap AMO/QC Manual PT. MSTech.

PENGAWASAN

KNKT.15.10.24.04 - PT.

Asian One Air Tecnam

P2006T Aircraft; PK-LTK

Nusawiru Airport

Pangandaran, Jawa

Barat 20 October 2015

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016Directorate General


To develop guideline of single pilot resource management as a reference for

the single pilot operators.OPEN 24-Nov-2016 NIL PENGAWASAN

KNKT.15.10.24.04 - PT.

Asian One Air


PK-LTK

Nusawiru Airport

Pangandaran,

Jawa Barat

20 October 2015

PK-LTK 20-Oct 2015 Final Report 26-Aug 2016Directorate General


To improve audit and surveillance system to organisation which have

authorization to conduct maintenance activity includes assembling of aircraft.OPEN 24-Nov-2016 NIL PENGAWASAN

13

KNKT.15.10.25.04 - PT.

Enggang Air Service

Cessna 208B Grand

Caravan; PK-RSE

Sinak Airport, Papua


27 October 2015

PK-RSE 27-Oct 2015 Preliminary Report 20-Jun 2016 Enggang Air Services 04 O 2016 60 1 To emphasize the pilot emergency training related to engine malfunction. CLOSED 18-Sep-2016Has been implementing Recovery Training Post Serious

Incident on 1st December 2015.PENGAWASAN

11

12



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LTK Final Report (ISBN).pdf






http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary Report PK-RSE.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.11.26.04 - PT.

Batik Air Indonesia

Boeing 737-900 ER; PK-

LBO

Adisutjipto International

Airport

Yogyakarta, Republic of

Indonesia

6 November 2015

PK-LBO 6-Nov 2015 Final Report 9-Jun 2016 Batik Air 04 O 2016 20 1To improve the crewmember emergency training to ensure all crewmembers

performs the evacuation according to the company proceduresCLOSED 7-Sep-2016

1. Batik Air has changed Manual of Training, from

Operation Training Manual (OTM) 02 October 2015 to

Operation Manual D (Training Manual) OMD, 27

January 2016.

2. Chapter Crewmember Emergency Training has

changed:

• curriculum segment

• content of module

• add subchapter record keeping

3. Training of Crewmember Emergency Training, has

been conducting until now with new training manual.

ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015

PK-LBO 6-Nov 2015 Final Report 9-Jun 2016

Angkasa Pura I

Branch Office

Adisutjipto


04 B 2016 22 1To perform daily inspection of the movement area as specified in the

Aerodrome Manual (AM) and airport Standard Operating Procedure (SOP).CLOSED 21-Sep 2016 7-Sep-2016

The daily inspection performed three times a day in

accorndance with the AM and SOP.PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


Angkasa Pura I

Branch Office

Adisutjipto


04 B 2016 23 1

To develop procedure for measurement of water depth in runway and taxiway

as required by chapter 4.5 of Appendix 1 Civil Aviation Safety Regulation

(CASR) Part 139 Volume I.

CLOSED 21-Sep 2016 7-Sep-2016

Standing water measurement has not been able to be

conducted as the method and equipment have not

available, it requires further discussion.

ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


Angkasa Pura I

Branch Office

Adisutjipto


04 B 2016 24 1To update the AM and SOP, and implement the runway friction measurement

according to the specified in the Advisory Circular (AC) CASR Part 139-23.CLOSED 21-Sep 2016 7-Sep-2016

Implementation of runway friction test described in the

AM chapter 4.7.7ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


Angkasa Pura I

Branch Office

Adisutjipto


04 B 2016 25 1

To develop a reporting system to enable disseminate significant information

of runway condition to Air Traffic Service (ATS) unit and for those units to

provide the necessary information to arriving and departing aircraft without

delay as required in ICAO Annex 14 Chapter 2.9.1.

CLOSED 21-Sep 2016 7-Sep-2016 Reporting system has not been established. ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


Angkasa Pura I

Branch Office

Adisutjipto


04 B 2016 51 1To review the possibility of development an instrument approach for runway

27.CLOSED 21-Sep 2016 7-Sep-2016

The airport sent letter to AirNav Indonesia to review

the possibility of development an instrument approach

for runway 27

PRASARANA

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


AirNav Indonesia

District Office

Yogyakarta

04 A 2016 26 1To provide the tower controller with the current weather information by

installation of AWOS display monitor in the tower control desk.CLOSED 19-Sep 2016 7-Sep-2016

Provided wind and pressure indicator system in the

Tower working spacePRASARANA

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


AirNav Indonesia

District Office

Yogyakarta

04 A 2016 51 2To review the possibility of development an instrument approach for runway

27.CLOSED 19-Sep 2016 7-Sep-2016

Conducted review and analysis of RNP approach for

runway 27 with aircraft operators.PRASARANA

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015

PK-LBO 6-Nov 2015 Final Report 9-Jun 2016Directorate General

of Civil Aviation04 R 2016 1 2 To emphasize all aircraft operators comply with stabilize approach criteria. OPEN 7-Sep-2016 NIL PENGAWASAN

14

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/Final Report PK-LBO.pdf












NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To ensure all aircraft operators calculate the landing distance available is

suitable for the landing distance required on existing condition.OPEN 7-Sep-2016 NIL PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To emphasize all aircraft operators implement standard callout procedure on

approach.OPEN 7-Sep-2016 NIL PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To emphasize all aircraft operators conduct emergency training to ensure the

crewmember taking appropriate action during emergency.OPEN 7-Sep-2016 NIL PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To ensure that the airport operators manual contain the requirement specified

in the CASR Past 139, AC CASR Part 139-23 and Manual of Standard CASR Part

139.

CLOSED 27-Feb 2018 7-Sep-2016

Direktorat Bandar Udara telah menerbitkan Peraturan

Direktur Jenderal Perhubungan Udara Nomor KP 212

Tahun 2017 tentang

Petunjuk Teknis Peraturan Keselamatan Penerbangan

Sipil Bagian 139-11, Prosedur Pengawasan Pavement

Management System (PMS) sebagai mekanisme untuk

memastikan operator bandar udara telah memenuhi

persyaratan pelaksanaan PMS

ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To ensure all airport operators conduct inspection of movement area

according to the approved manuals.CLOSED 27-Feb 2018 7-Sep-2016



Tahun 2017 tentang

Petunjuk Pelaksanaan Pengawasan Keselamatan

Operasi Bandar Udara dan Tempat Pendaratan dan

Lepas Landas Helikopter SI 139-01 sebagai mekanisme

untuk memastikan operator bandar udara telah

melaksanakan inspeksi area pergerakan dengan

frekuensi sebagaimana dipersyaratkan dalam MOS

Volume) Aerodrome

PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To ensure all airport operators implement the runway friction measurement

according to the specified in the AC CASR Part 139-23.CLOSED 27-Feb 2018 7-Sep-2016



Tahun 2017 tentang

Petunjuk Teknis Peraturan Keselamatan Penerbangan

Sipil Bagian 139-11, Prosedur Pengawasan Pavement

Management System (PMS) sebagai mekanisme untuk

memastikan operator bandar udara telah

mengimplementasikan pengukuran kekesatan runway

PENGAWASAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To include in the Indonesia regulation, the procedure of reporting system

from the airport operator to the ATS unit to enable disseminate significant

information of runway condition to arriving and departing aircraft without


CLOSED 27-Feb 2018 7-Sep-2016

dalam Peraturan Direktur Jenderal Perhubungan

Udara Nomor : KP 262 Tahun 2017 tentang Manual of

Standard (MoS) Part 139 Volume I Aerodrome Bagian

9.15.11 Operator Bandar Udara wajib

menginformasikan keberadaan air di permukaan

runway kepada Air Traffic Controller untuk dapat

disampaikan kepada penerbang sebagaimana bahan

pertimbangan braking action (good, medium, poor)

pada saat pendaratan

ATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015


of Civil Aviation04 R 2016 31 1 To issue approval certificates for the Air Traffic Services providers. CLOSED 7-Sep-2016

Issued approval certificate for ATS provider for

YogyakartaATURAN

KNKT.15.11.26.04 - PT.

Batik Air Indonesia


LBO


Airport


Indonesia

6 November 2015



To review the possibility of development an instrument approach for runway

27CLOSED 27-Mar 2018 7-Sep-2016

IAP runway 27 belum dapat dilakukan karena

bersinggungan dengan ruang udara Militer dan kondisi

Terrain yang cukup tingi di area approach.

PRASARANA

14













NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.12.28.04 - PT.

KalStar Aviation

Embraer 190-200LR; PK-

KDC

El Tari Airport

Kupang, Nusa Tenggara

Timur


21 December 2015

PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 16 1 To ensure the flight crew to perform appropriate crew briefing. CLOSED 10-May-2015Briefed all pilots regarding to the procedures and crew

briefing for landingPENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 17 1 To emphasize the flight crew to the stabilized approach criteria. CLOSED 10-May-2015Briefed all pilots regarding to the stabilized approach

criteriaPENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015 KalStar Aviation 04 O 2016 18 1To emphasize the flight crew to response to the aircraft warning system and

EGPWS warning appropriately.CLOSED 10-May-2015

Briefed all pilots regarding to response to the aircraft

and EGPWS warning system appropriately.PENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 73 2To ensure pilot performs the operational procedure such as checklist reading,

crew briefing properly and consistently.TDTL 25-Dec-2016 NIL PENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 78 1To develop oversight system that ensure the procedures are implemented

properly and to monitor pilot performance.TDTL 25-Dec-2016 NIL ATURAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Final Report 26-Sep 2016 KalStar Aviation 04 O 2016 79 1To ensure the comprehensive Safety Management System is implemented

correctly.TDTL 25-Dec-2016 NIL PENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Preliminary Report 9-Feb 2015

AirNav Indonesia

District Office

Kupang

04 A 2016 19 1To include in the Standard Operating Procedure (SOP) of ATC the procedure

for utilizing of visibility chart and determination of the wind information.CLOSED 10-May-2015

AirNav Indonesia district office Kupang updated the

Standard Operating Procedure (SOP) for the air traffic

controller to include the utilization of visibility chart

and determination of wind information

ATURAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Final Report 26-Sep 2016

Angkasa Pura I

Branch Office Eltari

Airport, Kupang

04 B 2016 25 2

To develop a reporting system to enable disseminate significant information

of runway condition to Air Traffic Service (ATS) unit and for those units to

provide the necessary information to arriving and departing aircraft without


OPEN 25-Dec-2016 NIL ATURAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015

PK-KDC 21-Dec 2015 Final Report 26-Sep 2016Directorate General

of Civil Aviation04 R 2016 1 3 To emphasize all aircraft operator to comply with stabilize approach criteria. OPEN 25-Dec-2016 NIL PENGAWASAN

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015



To ensure all aircraft operators implements safety management system as

required by Indonesia Civil Aviation Safety Regulation.OPEN 25-Dec-2016 NIL PENGAWASAN

15

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary Report PK-KDC.pdf



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-KDC Final Report (ISBN).pdf










NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.15.12.28.04 - PT.

KalStar Aviation


KDC

El Tari Airport


Timur


21 December 2015



To include in the Indonesia regulation, the procedure of reporting system

from the airport operator to the ATS unit to enable disseminate significant

information of runway condition to arriving and departing aircraft without


CLOSED 23-Feb 2018 25-Dec-2016

Sesuai dengan Peraturan Direktur Jenderal

Perhubungan Udara No. KP 262 Tahun 2017 Tentang

Mos Part 139 Volume I Aerodrome Bagian 9.15.11

PENGAWASAN

KNKT.16.02.13.04

PT AMUR AVIATION

INDONESIA - Hellicopter

Bell 206L-4; PK-UAG

Siriwo Area - Papua

3 February 2016

PK-UAG 3-Feb 2016 Final Report 5-Dec 2017Amur Aviation

Indonesia04 O 2017 3 1

The flight to Spot 99 was the first time for the pilot and was not accompanied

by a qualified pilot and prior to this flight appropriate briefing has not been

conducted therefore KNKT recommend to ensure that the flight to the specific

area shall comply with the requirement of company SOP or conduct risk

assessment to cover the operation to unfamiliar area.

TDTL 5-Mar-2018 The aircraft operator had been stopped the operation ATURAN

KNKT.16.02.13.04

PT AMUR AVIATION

INDONESIA - Hellicopter

Bell 206L-4; PK-UAG

Siriwo Area - Papua

3 February 2016

PK-UAG 3-Feb 2016 Final Report 5-Dec 2017Amur Aviation

Indonesia04 O 2017 3 2

Management assigned the pilot to conduct flight to Spot 99 that was the first

time for the pilot and was not accompanied by a qualified pilot and no

appropriate briefing prior to this flight has not been conducted which contrary

to the company SOP therefore KNKT recommend to emphasize the

management to improve the safety by conducting safety oversight to the

operation.

TDTL 5-Mar-2018 The aircraft operator had been stopped the operation ATURAN

KNKT.16.02.05.04 - PT.

Lion Mentari Airline

Boeing 737-900ER; PK-

LFG

Juanda International

Airport, Sidoarjo, East

Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 1

The deteriorating weather condition and difficulty of the SIC to control the

aircraft did not trigger a firm decision, therefore KNKT recommends to review

pilot training program in order to improve pilot decision making.

OPEN 4-Feb 2020 8-May-2017

1. The PIC may change over the control at any time to

ensure that the

highest level of safety is maintained. (OM-A8.3.1.5.3)

2. Pilot Decision Making Concept is part of CRM

training Syllabus on

Pilot program training in Operation Training Manual

(OM D 5.3.8)

3. Initial Training/Mandatory Training (OM-D 5.2.2)

4. Upgrading Training/Command Training (OM-D 5.2.6)

5. Re-Qualification Training (OM-D 5.2.7)

6. Recurrent Training, included on Recurrent/LOFT (OM-

PENGAWASAN

KNKT.16.02.05.04 - PT.



LFG



Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 2

During manual flying, the SIC had difficulty to control the aircraft that was

indicated by the activation of EGPWS hard alert ‘GLIDE SLOPE, GLIDE SLOPE’,

therefore KNKT recommends to review the procedure regarding the use of

autopilot and pilot training program in order to improve manual flying skill.

OPEN 4-Feb 2020 8-May-2017

1. Initial Training Lesson Plan

2. Line Training Lesson Plan (OTM 5.5.17)

3. Annual line check

PENGAWASAN

KNKT.16.02.05.04 - PT.



LFG



Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017Directorate General


To emphasize the other aircraft operator to review pilot training program in

order to improve pilot decision making. OPEN 8-May-2017 NIL PENGAWASAN

KNKT.16.02.05.04 - PT.



LFG



Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017Directorate General


To emphasize the other aircraft operator to develop training specifically

address the pilot recognition of situation in which the speed brakes, thrust

reverser and autobrake do not operates as expected after landing.

OPEN 8-May-2017 NIL PENGAWASAN

KNKT.16.04.07.04 -

Batik Air Indonesia and

TransNusa Aviation

Boeing 737-800 (PK-LBS)

and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma

International Airport,

Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016

AirNav Indonesia

District Office Halim

Perdanakusuma

04 A 2016 51 1

To develop procedure for all aircraft movement on the manoeuvring area

including the aircraft movement without aircraft own power, to communicate

with air traffic controller on the same frequency.

CLOSED 19-Sep 2016 2-Aug-2016

- Established ground control unit to control ground

movement which have different frequency from tower

controller, including its standard operation procedure.

- Established new procedure of ground movement to

taxi using perimeter service road.

ATURAN

15

18

16

17


http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016/2016 003 PK-UAG Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016/2016 003 PK-UAG Final Report.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2016 52 1To evaluate the current lighting of tower cab to prevent glare that may distract

controller view.CLOSED 19-Sep 2016 2-Aug-2016

Reduced the lighting on tower cab during low light

condition (night or cloudy situation).PRASARANA

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2016 53 1

To remind the ATC controller to maintain continues watch the aircraft

movement on the manoeuvring area, especially when issued air traffic control

clearance.

CLOSED 19-Sep 2016 2-Aug-2016

- Issued safety notice number

13.01/00/LPPNPI/04/2016/001 to improve the ATC

awareness for all movement in manoeuvring area.

- Put safety campaign poster in working area to

improve safety awareness while providing air

navigation services.

Conducted safety briefing to all ATS personnel

regarding safety awareness, hazard identification and

reporting culture.

PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2016 57 1To inform the aircraft operators to initiate takeoff from the threshold runway

24 of Halim Perdanakusuma International AirportCLOSED 19-Sep 2016 2-Aug-2016

Published NOTAM number A1268/16 NOTAMN to

remind all pilot to takeoff (open power) after the

threshold runway 24.

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2016 54 1To develop procedure for vehicle and aircraft on the manoeuvring area shall

be equipped with serviceable lights visible by air traffic controller.CLOSED 19-Sep 2016 2-Aug-2016

Issued safety notice to all aircraft operator, ground

handling service and fuel supplier service to include

the KNKT recommendation to their standard operating

procedure while operating vehicle and/or aircraft on

the manoeuvring area.

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017

AirNav Indonesia


Perdanakusuma

04 A 2017 7 7

It is recommended updating the SOP to accommodate controller coordination

to warrant the safe operation of aircraft and vehicle movement on

maneuvering area.

CLOSED 19-Sep 2016 9-Jul-2017 ATURANResponding to KNKT safety recommendation, on 7 April

2016, the AirNav Indonesia issued safety notice

addressed to all air traffic control units as follows:

a. Required all towing aircraft to switch on the

navigation lights.

b. Required all towing aircraft to communicate in

published tower frequency.

c. Required all vehicle without radio communication

entering maneuvering area shall be guided by “follow

me car”.

d. Required air traffic controller to record towing

movement on the flight progress strip.

e. Required to reduce the lights intensity in the tower

cab while providing air traffic services at night.

On 28 April 2016, issued NOTAM number A1268/16 for

all departure aircraft that using runway 24 to initiate

the acceleration for takeoff at threshold runway 24.

On 1 November 2016, issued NOTAM number

A3291/16, informed that the Halim Ground Control

services was operated for trial on frequency 118.6 Mhz

until 4 January 2017. On 3 January 2017, the Halim

Ground Control services trial was extended until 3 April

2017 and on 24 March 2017, the trial re-extended until

9 June 2017.

18

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LBS and PK-TNJ Final Report.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2017 7 8It is recommended to ensure the taxi or towing clearance issued contains

explicit limit to cross or to hold short of runway as required by AC 170.CLOSED 19-Sep 2016 9-Jul-2017 PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


AirNav Indonesia


Perdanakusuma

04 A 2017 7 9

It is recommended to reinforce the implementation of the KNKT

recommendation (04.B-2016-57.1) which is to inform aircraft operators to

initiate takeoff from the threshold runway 24 of HalimCLOSED 29-Nov 2018 9-Jul-2017

Published NOTAM number A1844/17 NOTAMN which

instructed all departure aircraft to initiate takeoff (open

power) after the threshold runway 24.

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


Angkasa Pura II

Branch Office Halim

Perdanakusuma


04 B 2016 57 1To inform the aircraft operators to initiate takeoff from the threshold runway

24 of Halim Perdanakusuma International AirportCLOSED 2-Aug-2016

Published NOTAM number A1268/16 NOTAMN to

remind all pilot to takeoff (open power) after the

threshold runway 24.

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


Angkasa Pura II

Branch Office Halim

Perdanakusuma


04 B 2016 54 1To develop procedure for vehicle and aircraft on the manoeuvring area shall

be equipped with serviceable lights visible by air traffic controller.CLOSED 16-Sep 2016 2-Aug-2016

Issued safety notice to all aircraft operator, ground

handling service and fuel supplier service to include

the KNKT recommendation to their standard operating

procedure while operating vehicle and/or aircraft on

the manoeuvring area.

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016


Angkasa Pura II

Branch Office Halim

Perdanakusuma


04 B 2017 7 9

It is recommended to reinforce the implementation of the KNKT

recommendation (04.B-2016-57.1) which is to inform aircraft operators to

initiate takeoff from the threshold runway 24 of HalimOPEN 9-Jul-2017 NIL PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016Directorate General


To develop procedure for vehicle and aircraft on the manoeuvring area shall

be equipped with serviceable lights visible by air traffic controllerCLOSED 24-Jan 2018 2-Aug-2016 Letter from DGCA 252/DBU/I/2018 ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Preliminary Report 4-May 2016Directorate General


To review a requirement for all aircraft movement on the manoeuvring area

including the aircraft movement without aircraft own power, to communicate

with air traffic controller on the same frequency.

OPEN 2-Aug-2016 NIL PENGAWASAN

Responding to KNKT safety recommendation, on 7 April

2016, the AirNav Indonesia issued safety notice

addressed to all air traffic control units as follows:

a. Required all towing aircraft to switch on the

navigation lights.

b. Required all towing aircraft to communicate in

published tower frequency.

c. Required all vehicle without radio communication

entering maneuvering area shall be guided by “follow

me car”.

d. Required air traffic controller to record towing

movement on the flight progress strip.

e. Required to reduce the lights intensity in the tower

cab while providing air traffic services at night.

On 28 April 2016, issued NOTAM number A1268/16 for

all departure aircraft that using runway 24 to initiate

the acceleration for takeoff at threshold runway 24.

On 1 November 2016, issued NOTAM number

A3291/16, informed that the Halim Ground Control

services was operated for trial on frequency 118.6 Mhz

until 4 January 2017. On 3 January 2017, the Halim

Ground Control services trial was extended until 3 April

2017 and on 24 March 2017, the trial re-extended until

9 June 2017.

18







NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017Directorate General


It is recommended to review the procedure of aircraft movement on

maneuvering area for airport operator and air navigation provider to

accommodate the requirement of CASR 91.209.

OPEN 9-Jul-2017 NIL PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016



It is recommended to review the requirement of personnel licensing for

towing car driver as required by the ICAO standard. OPEN 9-Jul-2017 NIL PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016



The CASR 170 Air Traffic Rules subpart 170.039 point (4) mentions the

statement “subject to the provisions in 3.8.3” that referred to chapter of ICAO

Annex 11.

It is recommended to review the contain of CASR to ensure its clarity

CLOSED 9-Jul-2017

Refer to Directorate of Air Navigation Letter No.

AU.304/4/115/DJPU.DNP.2017 dated 13 June 2017,

they are in the middle of CASR 170 revision in

according with ICAO Annex 11

PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016



Halim has runway length of 3,000 meters and was displaced 200 meters.

However, the published Aeronautical Information Publication (AIP) Volume I

Amendment 28, did not contain information that the total runway length is

reduced to 2,800 meters.

It is recommended to update the current published AIP.

CLOSED 9-Jul-2017

Refer to Directorate of Air Navigation Letter No.

AU.304/4/115/DJPU.DNP.2017 dated 13 June 2017, the

AIP of Halim Perdanakusuma Airport declared Landing

Distance Avaiable (LDA) is 2,800 metres

ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 1

It is recommended that the operator enhances the FCTM chapter 3.24

Rejected Takeoff Decision which is the PIC should announce the abnormality

simultaneously.OPEN 4-Feb 2020 9-Jul-2017

Operation Directorate revised the Operation Manual A

8.3.2.2.4 Rejection of Take-Off. (Appendix B)ATURAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 2

It is recommended that the operator to review the evacuation procedure and

consider the area can be observed through the viewing windows. OPEN 4-Feb 2020 9-Jul-2017

Operation Directorate revised SEP 1.4.5. Manual

regarding principles before opening exit(s) and warning

signals fligh crew to flight attendants on SEP 1.4.3.1

(Appendix C)

PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017TransNusa Aviation

Mandiri04 O 2017 7 3

Ensure the aircraft adequately lighted during night operation in accordance

with CASR 91.209. CLOSED 9-Jul-2017Quality Notice No. QN-TAM/018/IV/16 Tanggal 11

April 2016ATURAN

18











NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017TransNusa Aviation

Mandiri04 O 2017 7 4

Consider risk assessment, compliance to the regulation and specification

required prior to issue the Engineering Instruction. CLOSED 9-Jul-2017

Quality Notice No. QN-TAM/018/IV/16 Tanggal 11

April 2016PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017Jasa Angkasa

Semesta04 L 2017 7 5

It is recommended to review the requirement of personnel licensing for

towing car driver as required by the regulation standard, including the

language requirement.

OPEN 9-Jul-2017 NIL PENGAWASAN

KNKT.16.04.07.04 -


TransNusa Aviation


and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma


Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017Jasa Angkasa

Semesta04 G 2017 7 6

It is recommended to ensure the SOP of towing procedure is well

implemented.OPEN 9-Jul-2017 NIL PENGAWASAN

19

KNKT.16.04.09.04 -

Global Aviation Flying

School

Cessna 172 G, PK-TGL

Budiarto Airport,

Tangerang


28 April 2016

PK-TGL 28-Apr 2016 Final Report 12-May 2017Global Aviation

Flying School04 O 2016 9 1

To introduce the student pilots with Approach and Landing Accident

Reduction (ALAR) training and stabilize approach criteria and to emphasized a

go around shall be made when does not meet the criteria.

CLOSED 18-Feb 2020 10-Aug-2017

The Global Aviation Flying School conducted safety

briefing to all pilot about Approach and Landing

Accident Reduction (ALAR) using ALAR toolkit from

Flight Safety Foundation.

ATURAN

20

KNKT.16.05.10.04 -

PT.LION MENTARI

AIRLINES ; AIRBUS A330

& B737-800 ;

SOEKARNO-HATTA

AIRPORT ; 1 MAY 2016

PK-LEF & PK-LJR 1-Apr 2016 Final 8-Jun 2018 Lion Air 04 O 2018 10 1

The aircraft LNI077 was taxi in the narrow area and no ground assistance

provided to the pilot, therefore KNKT recommends to consider to stop or

request ground assistance during taxi in narrow area.

OPEN 4-Feb 2020 6-Sep-2018

1. Conduct re-training to flight crew with summary

2. Operation published company Internal Notam

(INTAM)

3. Safety & Security Directorate has been conducted

Risk Management

(14/RMR/VI/2016)

4. Safety & Security Directorate has been published

Safety Information

to All pilot (07/SS/SINF/V/2016)

ATURAN

KNKT.16.05.13.04 -

Etihad Airways

Airbus A330 -243; A6-

EYN

Near Bangka Islands


4 May 2016

A6-EYN 4-May 2016 Preliminary Report 8-Jun 2016 Etihad Airways 04 O 2016 58 2To enhance the safety reminder for passenger to fasten the seatbelt while

seating even though the seatbelt sign is off.CLOSED 6-Sep-2016

Etihad Airways currently have multiple instances on

each flight in which the passengers are advised to have

their seat belts fastened even when the seat belt signs

are switched off. The first is through public

announcements. These are made during the welcome

announcement made by the captain prior to departure

and the second announcement, made by the cabin

crew one minute after retraction of landing gear after

takeoff. These public announcements are made on all

passenger flights.

PENGAWASAN

KNKT.16.05.13.04 -

Etihad Airways

Airbus A330 -243; A6-

EYN

Near Bangka Islands


4 May 2016

A6-EYN 4-May 2016 Preliminary Report 8-Jun 2016 Etihad Airways 04 O 2016 59 1To ensure the pilot implementation of the Operations Manual Part-A chapter

12, subchapter 12.12.1 regarding declaration of urgency message.CLOSED 6-Sep-2016

The Etihad Airways issued a Flight Operations Message

(FOM-218) on 12-July-2016 reminding the entire Etihad

Airways flight crew community of the proper

phraseology and conditions to declare urgency.

PENGAWASAN

KNKT.16.05.13.04 -

Etihad Airways

Airbus A330 -243; A6-

EYN

Near Bangka Islands


4 May 2016

A6-EYN 4-May 2016 Final Report 27-Dec 2017 Etihad Airways 04 O 2016 13 1

The KNKT recommends the Etihad Airways to review the effectiveness of the

use of seatbelt policies to ensure passenger fastened their seatbelt when

seated.


KNKT.16.05.13.04 -

Etihad Airways

Airbus A330 -243; A6-

EYN

Near Bangka Islands


4 May 2016

A6-EYN 4-May 2016 Final Report 27-Dec 2017 Etihad Airways 04 O 2016 13 2

The KNKT recommends the Etihad Airways to ensure pilot conducts NITS

briefing after abnormal flight event as described in the Safety Emergency &

Procedure manual in the subchapter 8.1.2.


21

18




http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 09 PK-TGL Short Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 - 010 - PK-LEF and PK-LJR Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 13 A6-EYN Final Report.pdf





NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.05.13.04 -

Etihad Airways

Airbus A330 -243; A6-

EYN

Near Bangka Islands


4 May 2016

A6-EYN 4-May 2016 Final Report 27-Dec 2017Directorate General


KNKT recommends the DGCA to enforce the Indonesia aircraft operators to

review the effectiveness of the use of seatbelt policies to ensure passenger

fastened their seatbelt when seated.


21





NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.06.21.04 -

Nusa Flying School

Cessna 172P; PK-NIV

Demak, Central Java

06°48.094’S,

110°35.011’E


20 June 2016

PK-NIV 20-Jun 2016 Final Report 12-May 2017Nusa Flying

International04 O 2016 21 1

To review the training syllabus for instructor and student training to ensure

correct understanding to the aircraft system.CLOSED 10-Aug-2017

Seluruh instruktur memberikan arahan mengenai

sistem bahan bakar sesuai dengan checklist (Training

Syllabus).

PENGAWASAN

KNKT.16.06.21.04 -

Nusa Flying School

Cessna 172P; PK-NIV

Demak, Central Java

06°48.094’S,

110°35.011’E


20 June 2016

PK-NIV 20-Jun 2016 Final Report 12-May 2017Nusa Flying

International04 O 2016 21 2 To use fuel that meet the engine requirement. CLOSED 10-Aug-2017

Mengeluarkan Internal Memo (NFI/IO/01/VI/2016),

menggunakan 100%avgas.ATURAN

KNKT.16.06.21.04 -

Nusa Flying School

Cessna 172P; PK-NIV

Demak, Central Java

06°48.094’S,

110°35.011’E


20 June 2016

PK-NIV 20-Jun 2016 Final Report 12-May 2017Directorate General

of Civil Aviation04 R 2016 21 3 To ensure all instructors have adequate knowledge to the aircraft system. OPEN 10-Aug-2017 NIL ATURAN

KNKT.16.09.27.04 - PT.

Trigana Air Services

Boeing 737-300F; PK-

YSY



13 September 2016

PK-YSY 13-Sep 2016 Final Report 9-Jul 2020 Trigana Air Services 04 O 2020 27 1

KNKT recommend during approach descend about 400 feet AGL and the pilot

did not see the runway, the PM reminded to the PF that they were too far and

suggested to go around. The reminder and suggestion of the PM were not

taken by the PF indicated lack of crew coordination and resulted in the flight

continued the approach landing under the un-stabilized approach condition

and the weather that was not suitable for landing. KNKT recommends to

provide training for pilots to improve crew coordination.

OPEN 7-Oct-2020

KNKT.16.09.27.04 - PT.

Trigana Air Services

Boeing 737-300F; PK-

YSY



13 September 2016

PK-YSY 13-Sep 2016 Final Report 9-Jul 2020 Trigana Air Services 04 O 2020 27 2

The data download of the FDR installed on PK-YSY aircraft retrieved 20

parameters recorded on the FDR. The limited parameters recorded on the FDR

contributed to FDA analysis and investigation purposes. KNKT recommends to

ensure that all FDR installed are capable to record sufficient data as required

by the regulation

OPEN 7-Oct-2020

24

KNKT.16.10.32.04 - PT.

Asian One Air

Cessna 208B EX; PK-LTV

Ilaga Airport, Papua


13 October 2016

PK-LTV 13-Oct 2016 Preliminary Report 8-Oct 2016 Asian One Air 04 O 2016 94 1To ensure the operation of flights conducted under Visual Flight Rules (VFR)

performs according to the VFR limitations.CLOSED 20-Feb 2018 6-Jan-2017

Operation of flight conducted under Visual Flight

Rules (VFR) are described in the COM part 6.5PENGAWASAN

25

KNKT.16.11.40.04 - PT.

Nusa Flying

International

Cessna 172P; PK-NIZ

Adi Soemarmo



16 November 2016

PK-NIZ 16-Oct 2016 Preliminary Report 19-Dec 2016Nusa Flying

International04 O 2016 95 1

To ensure the maintenance action performed recorded in the Maintenance

Log Book.CLOSED 14-Mar 2018 19-Mar-2017

Management NFI mengeluarkan Internal Memo

(NFI/011/IOM/KS/III/2018), setiap

pekerjaan/inspection dan pergantian komponen ditulis

dan di record di maintenance Log Book.

PENGAWASAN

26

KNKT.16.10.37.04 -

Perkumpulan

Penerbangan Alfa

Indonesia

DHC – 4 Caribou,

PK‐SWW

Ilaga Pass, Papua


31 October 2016

PK-SWW 31-Oct 2016 Preliminary Report 29-Nov 2016

Perkumpulan

Penerbangan Alfa

Indonesia

04 O 2016 38 1

According to factual information and initial findings, the Komite Nasional

Keselamatan Transportasi (KNKT) recommend to Perkumpulan Penerbangan

Alfa Indonesia to comply the DGCA Safety Circular number SE.24 of 2016.

OPEN 27-Feb-2017 NIL PENGAWASAN

KNKT.16.12.43.04 - PT.

Wings Abadi Airlines

ATR 72-212A; PK-WGW

Ahmad Yani


Semarang


25 December 2016

PK-WGW 25-Dec 2016 Preliminary Report 24-Jan 2017 Wings Air 04 O 2016 43 1

The aircraft touched down and bounced twice. After the second bounce, the

pilot attempted to go around and the aircraft touched the runway. According

to the OM Part A and SOP for ATR 72-600 a go around shall be performed if a

hard and/or high bounce occurs. Therefore, KNKT recommends reviewing the

bounce recovery training for all pilots.

CLOSED 6-Jan 2017 24-Apr-2017

Wings Air issued notice to pilot which contained

instruction to review and adhere procedures as

described in the Operation Manual Part A and Quick

Reference Handbook as follows:

- OM-A 8.3.12 ADVERSE AND POTENTIALLY

HAZARDOUS ATMOSPHERIC CONDITIONS

- OM-A 8.1.1.2 PRE-FLIGHT INFORMATION

- OM-A 8.3.2.5.5 REQUIREMENT FOR STABILIZED FINAL

APPROACH

- OM-A 8.3.2.9.4 BOUNCED LANDING / LONG FLARE

- OM-A 8.3.2.10 GO-AROUND AND MISSED APPROACH

- OM-A 8.3.20.14 EVACUATION DIRECTIVES

- QRH 1.02 EMER EVACUATION ON GROUND

PENGAWASAN

KNKT.16.12.43.04 - PT.

Wings Abadi Airlines

ATR 72-212A; PK-WGW

Ahmad Yani


Semarang


25 December 2016

PK-WGW 25-Dec 2016 Preliminary Report 24-Jan 2017 Wings Air 04 O 2016 43 2

After the RFFS personnel arrived near the aircraft to assist the evacuation, the

tower controller advised the pilot to shut down the engines, thereafter the

engines were shutdown. This condition might harm the RFFS personnel and/or

passenger which evacuated before command by the flight crew members. It

also could prolong the evacuation process. Therefore, KNKT recommends

reviewing the emergency evacuation training including join training of flight

crew and flight attendant.

CLOSED 10-Jan 2017 24-Apr-2017

Wings Air issued notice to pilot which encourage all

simulator instructors to conduct additional training of

Bounce Landing Technique during pilot recurrent

session and review the Bounce Landing Technique

during pilot Line Training.

PENGAWASAN

27

22

23

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 21 PK-NIV Final Report.pdf



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 - 027 - PK-YSY Final Report.pdf


http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/PK-LTV Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/PK-NIZ Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/PK-SWW Preliminary Report.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.12.45.04 - PT.

ASI Pudjiastuti Aviation

Pilatus Porter PC-6, PK-

BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017Directorate General


KNKT recommend to the DGCA to review the runway length and consider to

extend the runway and provide the runway end safety area at the end of

runway 25 to minimize aircraft overrun and damaged to the aircraft in the case

of overrun occurred.

CLOSED 27-Feb 2018 6-Apr-2017

perpanjangan landas pacu dan pembualan RESA lelah

diprogramkan dalam kegialan Tahun Anggaran 2018

sebagai berikul :

1. Konslruksi perpanjangan dan peJebaran runway

Bandar Udara lIIaga dari

600 x 18 m menjadi 700 x 32 m lermasuk marking dan

pengawasan

(Perpanjangan runway dilaksanakan secara bertahap

sampai dengan 1150

x 30 m sesuai rencana induk);

2. Penyiapan lahan perpanjangan Bandar Udara Iliaga

Tahap II lennasuk

pengawasan.

a) Lahan area perpanjangan Tahap II difungsikan

sebagai RESA lerhadap

hasil perpanjangan runway Tahap I;

b) Panjang lahan yang akan lersedia yailu 210 m.

ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016



KNKT recommend to the DGCA to review the installation navigation aid such

as PAPI or VASI to prevent the visual illusion.CLOSED 27-Feb 2018 6-Apr-2017

lelah ada pakel pekerjaan pengadaan dan pemasangan

APAPI dan RTIL 1 ujung 1 sisi volume 1 pakel pada

runway 25 daJam Tahun Anggaran 2018.

ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016



KNKT recommend to the DGCA to consider to expand the apron dimension to

increase the capacity to be able to accommodate more aircraft. CLOSED 27-Feb 2018 6-Apr-2017

Apron Bandar Udara lIIaga lelah diprogramkan dalam

kegialan Tahun Anggaran 2017 dan 2018, sehingga

pada akhir Tahun 2018 akan lersedia apron dengan

dimensi 60 x 80 m (semula 30 x 60 m) dan laxiway

75 x 15 m (semula 19 x 18 mi.

ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016



KNKT recommend to the DGCA and AirNav Indonesia to establish the

standard departure and arrival route guidance to Ilaga and to review the

possibility of upgrading the air traffic services to aerodrome control area

(ADC).

OPEN 6-Apr-2017 ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016



KNKT recommend to the DGCA and Airnav Indonesia to review the facility

to support the performance of duty personnel.OPEN 6-Apr-2017 PENGAWASAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016


of Civil Aviation04 R 2016 45 8 KNKT recommend to the DGCA to review the aircraft operator SOP. OPEN 6-Apr-2017 NIL ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016



There was no direct VFR route from Timika to Ilaga based on the VFR route

which was published on Aeronautical Information Publication (AIP) Indonesia

Amendment 31 dated 5 April 2012, KNKT recommends to review and update

the VFR routes within area of Papua to include Timika - Ilaga.

CLOSED 27-Mar 2018 6-Apr-2017

Ditnavpen akan memprogramkan pembuatan rute

Timika-Ilaga dengan mengundang stake holder dan

Perum LPPNPI untuk pembahasannya.

ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017

Badan Meteorologi

Klimatologi dan

Geofisika

04 L 2016 45 10

Considering the number of flight per day and the availability of meteorological

station, KNKT recommends to the BMKG to consider the installation of

meteorology observation instrument in Ilaga

OPEN 6-Apr-2017 NIL ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 AirNav Indonesia 04 A 2016 45 11

To establish the standard departure and arrival route

guidance to Ilaga and to review the possibility of upgrading the air traffic

services to aerodrome control area (ADC).CLOSED 29-Nov 2018 6-Apr-2017

Revised visual departure, arrival and approach

procedure for Illaga Airport and had been inserted to

the AIRAC AIP Supplement number 19/17.

Conducted safety assessment to upgrade the ATS in

Ilaga from AFIS to TWR.

ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 AirNav Indonesia 04 A 2016 45 12to review the facility to support the performance of duty

personnel.CLOSED 29-Nov 2018 6-Apr-2017

AWOS and AFTN had been installed to support the ATS

in IlagaPRASARANA

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 13KNKT recommend to the aircraft operators to support the pilot decision and

not to apportion blame for pilot conducts RTB or diversion. OPEN 6-Apr-2017 NIL ATURAN

28

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NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 14KNKT recommend to the aircraft operator to consider the

used of bigger capacity aircraft type to reduce the frequency of flight to Ilaga.OPEN 6-Apr-2017 NIL ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 15

KNKT recommend to the aircraft operator to emphasize the EGPWS provider

to provide the high resolution terrain database in the mountainous area of

Papua.

OPEN 6-Apr-2017 NIL ATURAN

KNKT.16.12.45.04 - PT.



BVM

Ilaga Airport


31 December 2016

PK-BVM 31-Dec 2016 Preliminary Report 6-Jan 2017 Susi Air 04 O 2016 45 1

KNKT recommends to review the pilot qualification and requirements to fly to

an airport with special circumstances such as Ilaga. OPEN 6-Apr-2017 NIL PENGAWASAN

KNKT.17.01.02.04 ; PT.

MANDIRI UTAMA

FLIGHT ACADEMY ;

BLIMBINGSARI

AIRPORT, BANYUWANGI

; 16 JANUARI 2017

PK-MUA 16-Jan 2017 Final 8-Jun 2018Mandiri Utama Flight

Academy4 O 2018 2 1

KNKT recommend to improve the training including demonstration to ensure

student pilots understanding of correct approach and landing technique.TDTL 6-Sep-2018

Follow up recommendation could not be confirmed.

The aircraft operator is no longer operation.ATURAN

KNKT.17.01.02.04 ; PT.

MANDIRI UTAMA

FLIGHT ACADEMY ;

BLIMBINGSARI

AIRPORT, BANYUWANGI

; 16 JANUARI 2017

PK-MUA 16-Jan 2017 Final 8-Jun 2018Blimbingsari Airport

Operator4 B 2018 2 2

KNKT recommend to improve the rescue and firefighting personnel training to

ensure the personnel ability to handle the actual emergency.OPEN 6-Sep-2018 NIL ATURAN

KNKT.17.01.02.04 ; PT.

MANDIRI UTAMA

FLIGHT ACADEMY ;

BLIMBINGSARI

AIRPORT, BANYUWANGI

; 16 JANUARI 2017

PK-MUA 16-Jan 2017 Final 8-Jun 2018Directorate General


Ineffectiveness of fire extinguishing process in Banyuwangi Airport may also

occur in other airports. KNKT recommend to review oversight process to

ensure the ARFF ability for extinguishing the fire effectively.

CLOSED 21-Nov 2018 6-Sep-2018

Direktorat Keamanan Penerbangan akan melaksanakan

audit terhadap Bandar Udara

Banyuwangi di bidang Rencana Penanggulangan

Keadaan Darurat Bandar Udara (Airport Emergency

Plan] dan Pertolongan Kecelakaan

Penerbangan dan Pemadam Kebakaran (PKP-PK) sesuai

dengan Surat Direktur Jenderal Perhubungan Udara

Nomor 1394/DKP/XI/2018 tanggal 06 November 2018

perihal audit AEP

dan PKP-PK.

PENGAWASAN

KNKT.17.02.06.04 - PT.

Garuda Indonesia

Boeing 737-800; PK-GNK


Airport, Yogyakarta


1 February 2017

PK-GNK 1-Feb 2017 Preliminary Report 29-Mar 2017

Angkasa Pura I

Branch Office

Adisutjipto


04 B 2017 6 1KNKT recommends ensuring that the runway centerline marking is clearly

visible during aircraft operation.CLOSED 27-Jun-2017

Sesuai dengan Surat Perjanjian Pengadaan Barang/Jasa

Nomor: PBJJOG-16001698 Bandara Internasional

Adisutjipto Yoyakarta dalam progress pelaksanaan

pekerjaan overlay sejak tanggal 31 Oktober 2016 s.d 29

April 2017. Pekerjaan pengecatan marka sementara

dan permanen termasuk Mrka Runway Centreline

Marking menjadi satun paket pekerjaan yang termuat

dalam kontrak tersebut.

PRASARANA

KNKT.17.02.06.04 - PT.

Garuda Indonesia

Boeing 737-800; PK-GNK


Airport, Yogyakarta


1 February 2017

PK-GNK 1-Feb 2017 Preliminary Report 29-Mar 2017

Angkasa Pura I

Branch Office

Adisutjipto


04 B 2017 6 2reviewing and or amending the inspection schedule to ensure the

implementation is consistent with such manuals,CLOSED 27-Jun-2017

Bandara Internasional Adisutjipto Yogyakarta saait ini

dalam proses pelaksanaan updating Aerodrome

Manual yang mana frekuensi inspeksi runway, taxyway

dan apron sudah disesuaikan dengan SOP menjadi dua

kali sehari.

Kegiatan inspeksi runway, taxyway dan apron di siang

hari telah dilaksanakan sejak tanggal 22 Maret 2017,

sesuai dengan Hasil Kesepakatan Bersama Rapat

Runway Safety Team tanggal 21 Maret 2017 dan sejak

tanggal 13 April 2017 kegiatan tersebut telah

dinotamkan.

PENGAWASAN

31

KNKT.17.03.09.04 - PT.

Pelita Air Service

ATR 72-212; PK-PAV

Halim Perdanakusuma


Jakarta


19 March 2017

PK-PAV 19-Mar 2017 Preliminary Report 31-May 2017 Pelita Air Services 04 O 2017 9 1To establish monitoring system in order to monitor the implementation of the

procedure for stabilized approach.CLOSED 5-Jun 2018 29-Aug-2017

PT. Pelita Iar Service issued Flight Safety Alert and

conducted Safety Stand Down related to the event and

the parties issued Safety instruction and Notice To Pilot

including but not limited to emphasize about syabilized

approach criteria and do not hesitate to go around if it

has not been met. Furthermore to establish monitoring

system for the implementation of stabilized approach

procedure, PT. Pelita Air Service has reviewed, revised

and conduct the SOP of Flight Data Analisys (FDA). The

flight-data is routinely analysed for safety related

events or trends, the causes of those problems are

identified and corected as required in all areas of flight

operations.

PENGAWASAN

29

30

28




http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 02 - PK-MUA FINAL Report.pdf



//192.168.0.9/../00 Investigation Data/2017/002 PK-MUA 14012017 Final/Correspondence/IN/Surat DKP ke KNKT - TL KNKT.17.01.02.04 (PK MUA).pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2017/PK-GNK Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2017/PK-GNK Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2017/PK-PAV Preliminary Report PRINT.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.17.05.17.04 -

PT.Sriwijaya Air

Boeing 737-300; PK-CJC

Rendani Airport, West

Papua - Republic of

Indonesia

31 May 2017

PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017 Sriwijaya Air 04 O 2017 17 1

During the approach between altitude 500 feet to 200 feet, the EGPWS aural

warnings “Sink Rate” and “Pull Up” active, however the pilot elected to land

the aircraft.

KNKT recommends the aircraft operator to improve the flight crew

understanding and application of Stabilize Approach Criteria.

OPEN 19-Dec-2017 NIL PENGAWASAN

KNKT.17.05.17.04 -

PT.Sriwijaya Air



Papua - Republic of

Indonesia

31 May 2017

PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017 Rendani Airport 04 B 2017 17 2

The runway observation and CCTV record indicated that standing water

present on the runway surface during and after rain and several runway lights

were covered by grass.

Refer to the aforesaid condition, KNKT recommends the airport operator to

takes necessary action to minimize the present of standing water and maintain

the runway lighting system alongside of runway.

OPEN 19-Dec-2017 NIL PRASARANA

KNKT.17.05.17.04 -

PT.Sriwijaya Air



Papua - Republic of

Indonesia 31 May 2017

PK-CJC 31-May 2017 Preliminary Report 20-Sep 2017Directorate General


Rendani airport has not held Aerodrome Certificate and the Aerodrome

Manual (AM) has not been approved by DGCA at the time of accident. KNKT

recommend DGCA to process the certification of aerodrome certificate for the

Rendani airport.

OPEN 19-Dec-2017 NIL ATURAN

KNKT.17.08.25.04 -

PT. Lion Airlines dan

PT. Wings Abadi Airlines


LJZ dan ATR 72-500;PK-

WFF

Kulanamu International

Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Airnav Indonesia 04 A 2017 25 1

KNKT recommends to ensure air traffic controller to comply with the

requirement of the AC170-02 and the ICAO Document 9432 if the conditional

clearance will be used.

CLOSED 3-Dec-2017

1. Meng-update dan ammandemend SOP ATS (Tower)

dengan refer AC170-02 dan ICAO Doc 9432.

2. Mensosialisasikan update dan amandement SOP ATS

9Tower) kepada seluruh personil ATC khususnya

Personil Tower

PENGAWASAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Airnav Indonesia 04 A 2017 25 2

KNKT recommends to ensure air traffic controller to listen to the read-back in

order to ascertain that the clearance or instruction has been correctly

acknowledged by the pilot and shall take immediate action to correct any

discrepancies revealed by the read back.

CLOSED 3-Dec-2017

1. Meng-update dan ammandemend SOP ATS (Tower)

dengan refer AC170-02 dan ICAO Doc 9432. 2.

Mensosialisasikan update dan amandement SOP ATS

9Tower) kepada seluruh personil ATC khususnya

Personil Tower

PENGAWASAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Airnav Indonesia 04 A 2017 25 3KNKT recommends air traffic controller to ensure all hazard on the runway is

properly mitigated without delay prior to issue takeoff or landing clearance.CLOSED 3-Dec-2017

Me-refresh kembali kepada seluruh personil ATC

khususnya personil Tower tentang prosedur Debris /

FOD di runway sesuai LOCA antara Perum LPPNPI

Kantor Cabang Madya Medan (Tower) dengan PT.

Angkasa Pura 2 Kualanamu (Unit Landasan)

PENGAWASAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Wings Air 04 O 2017 25 4

KNKT recommends all pilots to ensure clearances or instructions, including

conditional clearances, shall be read back or acknowledged in a manner to

clearly indicate that they have been understood and will be complied with.

CLOSED 3-Dec-2017

On 3 August 2017, issued notice to pilot number

42/NTP/OMIW/VIII/2017 which contained the

following instruction:

high level in all phase of flight.

ensure communications to or from the cockpit as well

as communications within the cockpit are restricted to

safety and operational related communications to

avoid distracting the flight crew from full attention to

aircraft maneuver and performance.

pilots before read back. If any doubt must be

reconfirmed to ATC.

PENGAWASAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Preliminary Report 4-Sep 2017 Wings Air 04 O 2017 25 5

KNKT recommends to ensure all pilots shall understand and comply the air

traffic controller instruction or clearance and to clarify when there is uncertain

instruction or clearance.

CLOSED 3-Dec-2017

On 5 August 2017, issued notice to pilot number

44/NTP/OMIW/VIII/2017 which contained the

following instruction:

departure runways. Always avoid (whenever possible)

depart from intersections.

crossing runways.

and good monitoring to ATC instructions.

PENGAWASAN

32

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NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 6The KNKT recommends to ensure air traffic controllers consider the possible

hazard when using RET for departure aircraft. CLOSED 7-Feb 2020

The AirNav Indonesia amended the ATS SOP for

Aerodrome Control Tower to include detail procedure

to use of Rapid Exit Taxiway (RET) as follows:

If controller will use RET for departure traffic, the

controller must consider:

- The use of RET will expedite and avoid delay, or to

optimize the use of runway;

- The remaining runway is sufficient for aircraft to

takeoff;

- No aircraft conducts landing approach on long

final/final/inbound heading; and

- No objection from pilot to use RET for takeoff.

The procedure for using RET for departure is as follows:

- Controller must advise the remain runway length to

the pilot;

- The use RET on opposite runway condition is

prohibited; and

- The use of conditional phrase/clearance is prohibited.

PENGAWASAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 7The KNKT recommends to review the ATS SOP to include detail procedure or

guideline for air traffic controller.OPEN 7-Feb 2020

The AirNav Indonesia amended the ATS SOP for

Aerodrome Control Tower including the prohibition to

use the use of conditional phrase/clearance is

prohibited.

ATURAN

KNKT.17.08.25.04 -





WFF


Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 8

The KNKT recommends to review the performance check or other methods of

maintaining air traffic controller competency to ensure the air traffic controller

ability to handle unusual condition of aircraft operation.

OPEN 27-Nov 2018 8-Jul-2018

The AirNav Indonesia branch office Medan developed

Unusual Condition procedure and included the Unusual

Condition procesure as briefing material during

performance check.

ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019 FlyingSAS 04 O 2018 10 1

The KNKT recommend the FlyingSAS to increase pilot awareness of their

medical condition and emphasize pilot who acquaint or experienced any

decrease in medical fitness which could cause incapacitation to report to

FlyingSAS management and the Director General of Civil Aviation.

CLOSED 1-Aug 2019 24-Aug-2019

Issued notice for all pilot to be more aware of their

medical condition and to report to the management

when suspected decrease in medical fitness thatc can

cause incapacitation.

PENGAWASAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019 FlyingSAS 04 O 2018 10 2The KNKT recommend the FlyingSAS to review and improve the hazard

reporting system including identification of operational safety issue.CLOSED 1-Aug 2019 24-Aug-2019

Issued notice to all FlyingSAS personnel which

reminded to report hazard.ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan

Penerbangan04 L 2017 10 3

The KNKT recommend the Aviation Medical Center to conduct the required

examination including ECG resting or ECG exercise in accordance with the

CASR part 67.

CLOSED 29-Jan 2020 24-Aug-2019

The Aviation Medical Center had developed an

integrated online medical record application which

included the exercises need to be completed based on

CASR part 67 as a default step to be completed in the

application. Special issuance for pilots who could not

performed or does not meet the requirement and

standard for ECG resting or exercise, shall be discussed

in Medical Review Board for further evaluation

ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan

Penerbangan04 L 2018 10 4

The KNKT recommend the Aviation Medical Center to conduct examiner

workload analysis to adjust the ration of examiner and applicant so that the

examination can be performed thoroughly.

CLOSED 29-Jan 2020 24-Aug-2019

The Aviation Medical Center (AMC) had reviewed the

ratio between examiner and their workload, and

conducted workload analysis. The result of the analysis

was the AMC need 11 examiners. After the accident,

the AMC had added 5 examiners and currently had 15

examiners in total.

ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Directorate General

of Civil Aviation04 R 2018 5

The KNKT recommend the DGCA providing method and address to report any

decrease in medical fitness which causes incapacitation by holder of medical

certificate.

OPEN 24-Aug-2019 ATURAN

33

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NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Directorate General

of Civil Aviation04 R 2018 6

The KNKT recommend the DGCA to review the implementation of Safety

Management System including hazard reporting system by aircraft operator in

regards to be able identifying operational safety issue.

OPEN 24-Aug-2019 PENGAWASAN

KNKT.17.11.33.04 - PT.

Wings Abadi Airlines &

BP3 Banyuwangi - ATR

72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 1The KNKT recommend to AirNav Indonesia to ensure air traffic controller

provides all necessary information to the accepting unit as stated in the SOP.CLOSED 7-Feb 2020

The AirNav Indonesia developed Rating Examination

Guidelines for Air Traffic Controller which included:

- 8 hours classroom briefing session to rehears

technical knowledge of air traffic control, including the

procedure of coordination with the adjacent units;

- theoretical check based on the classroom session

material;

- practical check during daily duty which included the

coordination procedures of information transfer and

update methods.

PENGAWASAN

KNKT.17.11.33.04 - PT.



72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 2The KNKT recommend to AirNav Indonesia to ensure air traffic controller

maintain listening watch to all communication.CLOSED 7-Feb 2020

The AirNav Indonesia developed Rating Examination

Guidelines for Air Traffic Controller which included:

- 8 hours classroom briefing session to rehears

technical knowledge of air traffic control, including the

requirement to maintain the listening watch;

- theoretical check based on the classroom session

material;

- practical check during daily duty which included the

requirement to maintain the listening watch.

The AirNav Indonesia conducted technical briefing for

all personnel before their duty which included the

PENGAWASAN

KNKT.17.11.33.04 - PT.



72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 BP3 Banyuwangi 04 O 2017 33 3The KNKT recommends the BP3B to ensure all student pilots to comply with

ATC clearance including assigned altitude and aware of the right of way.CLOSED 4-Mar 2019 29-Mar-2018

The BP3B issued notice to flight instructor and student

pilots which contained reminder:

- to maintain listening watch on the designated ATC

frequencies;

- to comply with ATC clearance including assigned

altitude, heading or sequence of traffic; and

- to follow right of way rules as stated on the Training

Procedure Manual.

PENGAWASAN

KNKT.17.11.33.04 - PT.



72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 BP3 Banyuwangi 04 O 2017 33 4The KNKT recommends the BP3B to ensure all student pilots maintain

listening watch to air traffic controller communication.CLOSED 4-Mar 2019 29-Mar-2018

The BP3B issued notice to flight instructor and student

pilots which contained reminder:

- to maintain listening watch on the designated ATC

frequencies;

- to comply with ATC clearance including assigned

altitude, heading or sequence of traffic; and

- to follow right of way rules as stated on the Training

Procedure Manual.

PENGAWASAN

KNKT.17.11.33.04 - PT.



72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 BP3 Banyuwangi 04 O 2017 33 5

The KNKT recommends the BP3B to ensure SD data card for data logging is

inserted in all aircraft that installed with Garmin G1000 for the purpose of

enhancing safety.

CLOSED 4-Dec 2017 29-Mar-2018The BP3B inserted SD card for data logging to all Cessna

172 aircraft that was equipped with Garmin G1000.PENGAWASAN

KNKT.18.01.01.04; PT.

Batik Air Indonesia dan

PT. Lion Mentari

Airlines; Airbus A320-

200 dan Boeing 737-

900ER; Near Waypoint

Tirus Surabaya, East of

Java

PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018 Batik Air 04 O 2018 1 1

The duty and flight hour of both pilot did not exceed the requirement of the

OM – Part A however, the slip of altitude clearance between the pilot mind

and the readback, the ability to monitor the other traffic communication and

feeling sleepy were indications of pilot fatigue. The fatigue might be caused by

overnight flight which increasing of potential fatigue was not fully recovered,

and the condition of the pilots woke up in early morning might reduce the

time for recovery sleep

Therefore, KNKT recommends the Batik Air to establish fatigue risk

management which may refer to ICAO Annex 6 and ICAO Document 9966.

OPEN 4-Feb 2020 22-Oct-2018

Operation Directorate revised the operation

administrative manual regarding operational planning

process to include the acclimatization.

The Safety Security and Quality Directorate published

the Quality Assurance Recommendation regarding

fatigue Risk Management Plan addressing Batik Air

Management.

ATURAN

KNKT.18.01.01.04; PT.

Batik Air Indonesia dan

PT. Lion Mentari

Airlines; Airbus A320-

200 dan Boeing 737-

900ER; Near Waypoint

Tirus Surabaya, East of

Java

PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018Directorate General


The Indonesia regulation of fatigue management is described in the Civil

Aviation Safety Regulation (CASR) Part 91. However, the regulation did not

contain detail guideline to establish fatigue risk management.

Therefore, KNKT recommends the DGCA to review the regulation for fatigue

risk management.

OPEN 22-Oct-2018 ATURAN

37

KNKT.18.03.08.04 -

Genesa Flying School

Super Decathlon 8KCAB;

PK-RTZ

Tunggul Wulung

Airport, Cilacap Central

Java


20 March 2018

PK-RTZ 20-Mar 2018 Final Report 24-Aug 2020 Genesa Dirgantara 04 O 2018 8 1

Based on the video footage, during the last maneuver, the aircraft initiated the

roll earlier and at lower altitude which not accordance to the requirement to

start roll is when the pitch 45° for the Cuban Eight or Cloverleaf maneuver.

The early roll resulted in the aircraft altitude too low during inverted which

was the initial altitude when the aircraft flying down and resulted in the

aircraft bounced to the apron during leveling off.

KNKT recommend the performance of aerobatic maneuver should follow the

minimum requirement of the aerobatic flight technique and the aircraft

performance.

OPEN 22-Nov-2020

34

35

36


http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 033 - PK-WHS & PK-BYK Final Report.pdf





//192.168.0.9/../00 Investigation Data/2018/001 PK-LUI & PK-LPF 06012018 - AirProx/Correspondence/OUT/Draft Final Report/PK-LUI & PK-LPF Draft Final Report .pdf

//192.168.0.9/../00 Investigation Data/2018/001 PK-LUI & PK-LPF 06012018 - AirProx/Correspondence/OUT/Draft Final Report/PK-LUI & PK-LPF Draft Final Report .pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018/2018 - 08 - PK-RTZ FINAL REPORT.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

38

KNKT,18,04,09,04 ;

PT.LION MENTARI

AIRLINES ; B737-900ER ;

ON ROUTE JAKARTA TO

JAMBI

PK-LFK 1-Apr 2018 Preliminary Report 8-Jun 2018 Lion Air 04 O 2018 9 1Improve the pilot training to ensure pilot understanding to the aircraft system

and performs procedure properly.OPEN 4-Feb 2020 6-Sep-2018

1. Lion Operational Training Department has been

revised syllabus

B737NG Recurrent (LOFT) 4, Issued 01 revision 01, 25

July 2018

‐page 9: MEL Discussion 21 – 01 ‐1c Air‐condition Packs

(-900/-

900ER) objective: trainee understand how to read and

when to set

ATURAN

39

KNKT.18.04.10.04 -

PT.WHITESKY AVIATION

- HELIKOPTER BELL 429 -

MOROWALI, SULAWESI

TENGAH

PK-WSX 20-Apr 2018 Preliminary Report 30-May 2018 Whitesky Aviation 04 O 2018 10 1

The operator utilized the company quick reference handbook (QRH) that was

derived from the manufacture manual where the significant part was missing

from the QRH, KNKT recommend to the operator to review and revised the

checklist to refer to the manufacture checklist.

OPEN 28-Aug-2018 NIL ATURAN

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 009 - PK-LFK Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 010 - PK-WSX Preliminary Report.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

40

KNKT.18.04.12.04 - PT.

Lion Mentari Airlines;

Boeing 737-800;

Djalaluddin Airport,

Gorontalo

PK-LOO 29-Apr 2018 Preliminary Report 30-Jun 2018 Djalaluddin Airport 04 B 2018 12 1

The crash bell had not been connected to the Airport Rescue and Fire Fighting

(ARFF) station. KNKT recommend Djalaluddin Airport Operator to establish all

equipment required for the standard airport services.

OPEN 28-Sep-2018 PRASARANA

KNKT.18.05.18.04 -

Garuda Indonesia

CRJ 1000; PK-GRJ and

Wings Air

ATR 72-500; PK-WFW

Left Downwind Runway

10, Tambolaka Airport


PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020Airnav Indonesia

District Tambolaka04 A 2018 18 1

The Air Traffic Services (ATS) provided in Tambolaka Aerodrome Flight

Information Zone (AFIZ) were flight information, alerting, and, if required, air

traffic advisory services. The Tambolaka ATS provider did not provide air traffic

control services that contain clearance and/or instructions, as the airspace of

the Tambolaka was Class G airspace.

Some advice from the ACO given to the pilot used instruction phraseology,

and the pilot sometimes requested a clearance to the ACO. These mixed-up

communications indicated unclear determination of service status between air

OPEN 8-Oct-2020

KNKT.18.05.18.04 -

Garuda Indonesia


Wings Air

ATR 72-500; PK-WFW




PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Garuda Indonesia 04 O 2018 18 2

One day before the day of the occurrence, the GIA460 PF was felt unfit and on

the following day after the occurrence, the PIC was hospitalized. The

investigation considered that on the day of the occurrence the PIC medical

condition might reduce his performance.

The OM-Part A of Garuda Indonesia described that pilot must maintain their

performance in physical fitness and pilot is prohibited to fly when unfit. The

pilot may refuse their duty if unfit by submitting an unfit statement letter

according to the Pedoman Awak Pesawat (Flight Crew Guidance).

OPEN 8-Oct-2020

KNKT.18.05.18.04 -

Garuda Indonesia


Wings Air

ATR 72-500; PK-WFW





The readback from GIA460 PM that the WON1921 would join left downwind

runway 10 indicated that the PM had acknowledged the WON1921 pilot

intention. However, when the GIA460 PF advised the PM that WON1921

would join right downwind runway 10, made the PM followed the PF

assumption and disregarded the WON1921 information. The absence of pilot’s

discussion to assess of WON1921 flight properly indicated that Crew Resource

Management was not implemented properly.

The OM-Part A subchapter 11.11.1 described that Crew Resource

OPEN 8-Oct-2020

KNKT.18.05.18.04 -

Garuda Indonesia


Wings Air

ATR 72-500; PK-WFW










However, some advice from the ACO given to the pilot used instruction

phraseology, and the pilot sometimes requested a clearance to the ACO.

These mixed-up communications indicated unclear determination of service

OPEN 8-Oct-2020

KNKT.18.05.18.04 -

Garuda Indonesia


Wings Air

ATR 72-500; PK-WFW




PK-GRJ & PK-WFW 11-May 2018 Final Report 10-Jul 2020 Wings Air 04 O 2018 18 5






However, some advice from the ACO given to the pilot used instruction

phraseology, and the pilot sometimes requested a clearance to the ACO.

These mixed-up communications indicated unclear determination of service

OPEN 8-Oct-2020

KNKT.18.06.24.04 -

FlyingSAS; Cessna 208B;

Nabire, Papua; 18 Juni

2018

PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 FlyingSAS 04 O 2018 24 1

The stored GPS flight plan route on PK-FSP aircraft and the Route Information

published by FlyingSAS on OM – Part C contained checkpoint TOPO for route

Bilorai to Nabire while the stored GPS flight plan route on the PK-FSL aircraft

and VFR Route Chart published on OM – Part C was not containing checkpoint

TOPO.

KNKT recommends the FlyingSAS to ensure the route guidance for pilot

contains same information.

OPEN 9-Oct-2018 PENGAWASAN

KNKT.18.06.24.04 -



2018

PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018 AirNav Indonesia 04 A 2018 24 2

The AIP Volume IV of Nabire published by the DGCA contained different

coordinate of the NBR VOR/DME location.

KNKT recommends the AirNav Indonesia to provide correct information of the

NBR VOR/DME location to the DGCA and also review the possibility of other

incorrect coordinate of navigation aid prior to publish in the AIP.

OPEN 29-Nov 2018 9-Oct-2018

Conducted location check to the actual location of the

NBR VOR/DME and published NOTAM to disseminate

the correct coordinate of the NBR VOR/DME. Planned

to revise the AIP Volume IV of the NBR VOR/DME

coordinate.

PRASARANA

KNKT.18.06.24.04 -



2018

PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018Directorate General


In 2017, KNKT issued safety recommendation number 04.R-2015-17.6 which

was recommend the Directorate General of Civil Aviation (DGCA) to publish

the visual route guidance for airport without instrument approach procedure

and responded that the DGCA offered aircraft operator to submit draft visual

guidance to DGCA and AirNav Indonesia for further discussion.

During this occurrence, the AIP Volume IV did not include approach guidance

for Nabire. The FlyingSAS issued route information of Nabire and Visual Flight

Rules (VFR) chart for route Nabire – Sugapa (Bilorai) and return, this guidance

was used for internal purpose.

KNKT recommends the DGCA to ensure that the safety recommendation

number 04.R-2015-17.6 which published in 2017 is performed for all

Indonesian airports without instrument approach procedure.


KNKT.18.06.24.04 -



2018

PK-FSL 18-Jun 2018 Preliminary Report 11-Jul 2018Directorate General


The AIP Volume IV of Nabire published by the DGCA contained different

coordinate of the NBR VOR/DME location.

KNKT recommends the DGCA to determine the correct coordinate of NBR

VOR/DME and also review the possibility of other incorrect coordinate of

navigation aid in the AIP.


KNKT.18.06.25.04; PT.

Wings Abadi Airlines;

ATR 72-212; Sintang,

West Kalimantan; 19

June 2018

PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 Wings Air 04 O 2018 25 1

The flight was the first flight for the PIC and SIC to Tebelian Airport and there

was no briefing related to the operation of new airport, therefore KNKT

recommends to ensure the pilot provide with the current information before

conducting flight.

CLOSED 21-Aug 2018 28-Oct-2018

Short Term :

On June 25, 2018 - SSQ published Safety Notice 008

Date 25/06/2018 Landing or Attepted Landing on a

closed runway or taxi way

On June 28, 2018 - Operation Wings Air published

Notice to All Crews, NTA/001/VI/2018 Upstream

Defenses to prevent landing or Attepted Landing on a

Closed Runway or Taxi Way.

On June 22, 2018 – Flight Standard input AVG Tebelian,

Sintang on File Management System

Long Term :

On August 3, 2018 – Operation made Training Review

Board (CRM), modules review of serious incident

Sintang - (Done)

On August 15, 2018 – Evaluation for Material CRM

between Training Departement Wings Air and ATC

(Angkasa Training Centre) – (Done)

PENGAWASAN

42

43

41

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 012 - PK-LOO Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2018 - 18 - PK-GRJ & PK-WFW Final Report.pdf





http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 024 - PK-FSL Preliminary Report.pdf




http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 025 - PK-WHF Preliminary Report.pdf




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.18.06.25.04; PT.



West Kalimantan; 19

June 2018

PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018 Wings Air 04 O 2018 25 2

The aircraft had document library which contained several documents

including Airport Visual Guidance (AVG). The aircraft document library was

updated on January 2018, while the AVG revision status was number 5 dated

25 August 2017. The AVG of the Sintang Airport available on the aircraft library

and utilized by the pilot was published on 2 March 2018 and effective since 9

March 2018, therefore KNKT recommends to ensure all the document

provided for the flight operation up to date and properly documented.

CLOSED 21-Aug 2018 28-Oct-2018

The flight Standard Depatement is responsible for

ensuring that any revision to this manual are in the on

line version. This OM will be controlled and current

only in this webside and available on line in File

Management System.

(OAM – Operation Administration Manual, Preamble

page 4/18, Electronic (Soft Copy).

Short term :

The Flight Standard Departement already input AVG

SINTANG on June 22, 2018 – 10:23:40 wib.

Long Term :

All change in Airport Visual Guidance wil rised on

Management of Change – and sure process distribute

AVG to all controlled library.

PENGAWASAN

KNKT.18.06.25.04; PT.



West Kalimantan; 19

June 2018

PK-WHF 19-Jun 2018 Preliminary Report 30-Jul 2018Directorate General


On the AIP, the coordinate of TB NDB position was written 000230.07 S and

1112713.13 E, this format is not clearly describe decimal degrees format or

degrees-minutes-second format, therefore KNKT recommends to ensure the

standard coordinate format in the AIP.


KNKT.18.06.25.04; PT.



West Kalimantan; 19

June 2018



On the day of the occurrence, the Sintang Aiport information available on the

website on page link AIP Volume IV contained information of Susilo Airport

which had been closed for operation. The information of the Tebelian Airport

available in the website on page link AIP Supplement, therefore KNKT

recommends to ensure only the current information available in the

publication and to remove the overdue information.


KNKT.18.06.25.04; PT.



West Kalimantan; 19

June 2018



The un-serviceability mark of white cross on runway of Susilo Airport had not

been completed at that time of occurrence, therefore KNKT recommends to

ensure the process of airport certification are properly conducted before

release amendment of aerodrome certificate.


PK-HVQ 11-Aug 2018 Preliminary Report 5-Oct 2018 Dimonim Air 04 O 2018 32 1KNKT recommends the Dimonim Air to ensure all flights are conducted at or

above the required weather minima.OPEN 3-Jan-2019 PENGAWASAN

PK-HVQ 11-Aug 2018 Preliminary Report 5-Oct 2018Directorate General


KNKT recommends the DGCA to ensure that the safety recommendation

number 04.R-2015-17.6 which published in 2017 and 04.R-2018-24.3 in 2018

to publish the visual route guidance for airport without instrument approach

procedure.

OPEN 3-Jan-2019 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,

West Java; 29 October

2018

PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 1

Refer to the CASR Part 91.7 Civil Aircraft Airworthiness and the Operation

Manual part A subchapter 1.4.2, the pilot in command shall discontinue the

flight when un-airworthy mechanical, electrical, or structural conditions occur.

The flight from Denpasar to Jakarta experienced stick shaker activation during

the takeoff rotation and remained active throughout the flight. This condition

is considered as un-airworthy condition and the flight shall not be continued.

KNKT recommend ensuring the implementation of the Operation Manual part

A subchapter 1.4.2 in order to improve the safety culture and to enable the

pilot to make proper decision to continue the flight.

CLOSED 4-Feb 2020 26-Feb-2019

1. Lion Air had emphasized the Operation Manual part

A (OM-A) Chapter 1.4.2.

2. Lion Air had issued the Safety Notice

16/SS/SN/XI/2018 Lion Emergency Flowchart-Revision

Nov 2018.

3. Lion Air had issued Temporary Revision (TR) on

Safety Management Manual (SMSM) Number

01/ERM/XI/2018 on Lion Emergency Flowchart.

4. Short term: Flight Operation had published NTP

30/NT/XI/2018 Flight Following OM-A 236 to all pilot

regarding OM 2.3.6 (Flight Following).

5. Lion Air had issued LA-OT-02-PILOT-02-11 B737

Recurrent 5 Trainee Lesson Plan.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 2

According to the weight and balance sheet, on board the aircraft were two

pilots, five flight attendants and 181 passengers consisted of 178 adult, one

child and two infants. The voyage report showed that the number of flight

attendant on board was six flight attendants. This indicated that the weight

and balance sheet did not contain actual information.

KNKT recommend ensuring all the operation documents are properly filled

and documented.

CLOSED 4-Feb 2020 26-Feb-2019

1. Lion Air had coordinated with Angkasa Aviation

Services (AAS) and they had issued Quality Assurance

Notice 102/AQ-AAS/N/XII/2018 on Akurasi Konfigurasi

Crew di Pesawat.

2. Chief Pilot had published Notice to Pilot

010/NTP/II/2019 SAFETY and SERVICE IMPROVEMENT

regarding cross check crew composition with Flight

Attendant and Ramp officer.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 3KNKT recommends establishing system to ensure the company manuals are

updated in timely manner.CLOSED 4-Feb 2020 23-Jan-2020

3. To ensure the company manual are updated in

timely manner:

- Lion Air has been revised COM 6.4.6.1 regarding

Document Review

(TR 11/TR/COM-JT/XII/2019)

- Lion Air has been publishing notice: QAN-

05/DQ/XII/2019: Manual Synchronization

ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 4KNKT recommends that Lion Air review the SMS training material and the

duration of trainingCLOSED 4-Feb 2020 23-Jan-2020

1. Lion Air has been revised SMS training syllabus:

-Initial [LA-SS-03-01-54] Rev 2 2019

Recurrent [LA-SS-03-01-55] Rev 2 2019

Material:

-Initial [LA-SS-03-01-49] Rev 7 2019

Recurrent [LA-SS-03-01-52] Rev 2 2019

Revision of SMSM related 7.4.2 General safety

Management System Training (TR 1/SMSM/XII/2019).

2. Lion Air has been revised duration of SMS training.

3. Lion Air has been inserted Training case of JT43 and

PENGAWASAN

43

44

45

KNKT.18.08.32.04; PT.

Marta Buana Abadi

(Dimonim Air); PAC

750XL; Menuk

Mountain Oksibil

Papua; 11 August 2018





http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 031 - PK-HVQ Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 031 - PK-HVQ Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 035 - PK-LQP Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 035 - PK-LQP Preliminary Report.pdf

//192.168.0.9/../01 FINAL REPORT Published per year/2019/2018 - 033 - PK-LQP Final Report.pdf





NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 5recommends that Lion Air improve their hazard report management enabling

identifying the hazard and provides proper mitigation.CLOSED 4-Feb 2020 23-Jan-2020

To improve Lion Ops Personnel knowledge regarding

hazard identification:

-Lion Air has been published Monthly Bulletin edition

Nov 2019 vol 58, add content example of hazard report

from CORUSON (continue program to next edition)

-Lion Air has been conducted safety campaign

regarding hazard identification and hazard reporting:

station SOC (24 July 2019), station JOG (25 July 2019),

CGK (16 August 2019 FMM Management (11 July

2019), ME 121 (2 Dec 2019)

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 6KNKT recommends emphasizing engineers to record test values as required by

the BAT LMPMOPEN 23-Jan-2020 PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 7KNKT recommends establishing system to ensure the company manuals are

updated in timely manner.OPEN 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Batam Aero Technic 04 MO 2018 35 8KNKT recommends that Batam Aero Technic establish policy and procedure of

handling OMFOPEN 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 AirNav Indonesia 04 A 2018 35 9KNKT recommends providing information to the flight crew that the altitude

indication on the ATC radar display was repeating data from the aircraftCLOSED 8-Jan 2020 23-Jan-2020

AirNav Indonesia issued circular to all branch office

which contained instruction to review and amend the

Standard Operation Procedure for ATS to include:

1. Information that pressure-altitude-derived level

information of aircraft on the situational display (radar

display) is come from aircraft.

2. Additional phraseology to be used by air traffic

controller when responding pilot question of their

aircraft altitude, as follows: ALTITUDE/LEVEL

INDICATION IS REPEATING DATA FROM YOUR

AIRCRAFT, YOUR ALTITUDE/LEVEL (altitude/level).

ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Xtra Aerospace 04 MO 2018 35 10

KNKT recommends emphasizing the implementation of a company manual

including equivalency assessment, training and written procedure, to ensure

component being repaired are properly maintained

TDTL 17-Jan 2020 23-Jan-2020

On 24 October 2019 the company surrendered its

repair station certificate and no longer performs

component maintenance or otherwise exercises the

privileges of a repair station. Accordingly, there is no

need for Xtra to take any further actions.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 11

KNKT recommends that the aircraft manufacture to consider the effect of all

possible flight deck alerts and indications on flight crew recognition and

response; and incorporate design, flight crew procedures, and/or training

requirements where needed to minimize the potential for flight crew actions

that are inconsistent with manufacturer assumptions

CLOSED 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 12KNKT recommends that Boeing include a larger tolerance in the design is

required to allow operability by a larger population of flight-rated pilotsCLOSED 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 13

KNKT recommends that Boeing and the FAA more closely scrutinize the

development and certification process for systems whose malfunction has the

ability to lead to loss of control of the airplane.

CLOSED 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 14KNKT recommends to Boeing to develop the guidance for the criteria of

information which should be included in flight crew and engineer’s manualsCLOSED 23-Jan-2020 ATURAN

45














NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 15KNKT recommends to Boeing that they ensure that certified and delivered

airplanes have intended system functionalityCLOSED 23-Jan-2020 PENGAWASAN

45





NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 16KNKT recommends the IFIM tasks sequence are reviewed to ensure they are

effective.CLOSED 28-Nov 2019 23-Jan-2020

On 15 November 2019, Boeing published a revision to

the IFIM in which the repetitive step has been

removed from the following tasks.

‐ IFIM Task 34‐10‐00‐810‐801 – Capt IAS Disagree

‐ IFIM Task 34‐10‐00‐810‐802 – FO IAS Disagree

‐ IFIM Task 34‐20‐00‐810‐801 – Capt ALT Disagree

‐ IFIM Task 34‐20‐00‐810‐802 – FO ALT Disagree

‐ IFIM Task 34‐24‐00‐810‐812 – Integrated Standby

Flight Display: Altitude display disagrees with primary

display

ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019Directorate General


KNKT recommends improving oversight to ensure implementation of the

standard procedure.OPEN 23-Jan-2020 PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018



KNKT recommends improving the oversight of the manual to ensure the

manuals are conform to the standard and updated in timely mannerOPEN 23-Jan-2020 PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018



KNKT recommends that the Directorate General of Civil Aviation review

operators SMS training material and the duration of training to ensure

adequacy of SMS implementation


KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019United States Federal

Aviation

Administration

04 RL 2018 35 20

KNKT recommends to review the requirements of the applicable FARs to

consider any issue that may be overlooked when the requirements are

considered separately


KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 21

KNKT recommends that the FAA review their processes for determining their

level of involvement (degree of delegation) and how changes in the design are

communicated to the FAA to ensure an appropriate level of review


KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 22

KNKT recommends that the FAA improves the oversight to Approved

Maintenance Organization (AMO) to ensure the processes within the AMO are

conducted in accordance with the requirements

OPEN 23-Jan-2020 PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 23

KNKT recommends that Boeing and the FAA more closely scrutinize the

development and certification process for systems whose malfunction has the

ability to lead to loss of control of the airplane


KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 24

KNKT recommends that the FAA work with international regulatory authorities

to review assumptions on flight crew behavior used during design and revise

certification processes to ensure assumptions used during the design process

are validated.


KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 25

KNKT recommends to the FAA work with international regulatory authorities

to review the guidance for the criteria of information which should be

included in flight crew and engineer’s manuals


45














NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 26KNKT recommends to Boeing and the FAA that they ensure that certified and

delivered airplanes have intended system functionalityOPEN 23-Jan-2020 PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018


Aviation

Administration

04 RL 2018 35 27

KNKT recommends to the FAA work with international regulatory authorities

to review the requirements for installation of Non-Rechargeable Lithium

Battery certification requirements.


46

KNKT.18.12.41.04 PT.

Alfa Trans Dirgantara;

Cessna 208; Kasonaweja

Airstrip, Papua; 12

Desember 2018

PK-ASE 12-Dec 2018 Preliminary Report 29-Jan 2019 Alfa Trans Dirgantara 04 O 2019 41 1The KNKT recommends the Alfa Aviation to ensure SD data card for data

logging is inserted in all aircraft that installed with Garmin G1000 for the

purpose of enhancing safety.

TDTL 29-Apr-2019Follow up recommendation could not be confirmed.

The aircraft operator is no longer operation.PENGAWASAN

KNKT.19.03.08.04 - PT.

Air Transport Services -

Helikopter Bolkow BO

105 - Desa Jayaratu,

Tasikmalaya, Jawa Barat -

16 Maret 2019

PK-EAH 16-Mar 2019Immediate

Recommendation29-Mar 2019

Air Transport

Services04 O 2019 8 1

Meyakinkan management dan system perawatan dilaksanakan dengan benar

sesuai prosedur yang berlakuOPEN 27-Jun-2019 PENGAWASAN

KNKT.19.03.08.04 - PT.

Air Transport Services -

Helikopter Bolkow BO

105 - Desa Jayaratu,

Tasikmalaya, Jawa Barat -

16 Maret 2019

PK-EAH 16-Mar 2019Immediate

Recommendation29-Mar 2019

Air Transport

Services04 O 2019 8 2

Melaksanakan pemeriksaan ganda (double inspection atau required inspection

item) pada pekerjaan yang melibatkan flight control atau engine control. OPEN 27-Jun-2019 PENGAWASAN

KNKT.19.05.10.04 - PT.

Batik Air Indonesia -

Airbus A320 - Sultan

Hasanuddin

International Airport -

Sulawesi Selatan - 25

Mei 2019

PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batik Air 04 O 2019 10 1

KNKT recommend the Batik Air to review and amend procedure to enable CVR

data can be preserved for investigation following accident and serious

incident.

CLOSED 18-Oct 2019 27-Nov-2019

Batik Air amended the OM-part A subchapter 11.3.3

with detail description of event that requires pilot to

secure the CVR.

Batik Air issued safety notice for pilot, flight attendant,

engineer, line maintenance, flight operation officer

which highlighted the requirement to secure CVR on

the new subchapter 11.3.3

ATURAN

KNKT.19.05.10.04 - PT.



Hasanuddin



Mei 2019

PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batam Aero Technic 04 MO 2019 10 2

KNKT recommend the Batam Aero Technic to review and amend procedures

to enable accident or serious incident can be reported to the KNKT without

delay.


Batik Air issued safety notice for engineer, line

maintenance, flight operation officer which highlighted

the event that need to be reported to KNKT as soon as

possible.

ATURAN

KNKT.19.05.10.04 - PT.



Hasanuddin



Mei 2019

PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Batam Aero Technic 04 MO 2019 10 3

KNKT recommend the Batam Aero Technic to ensure all personnel working in

the aircraft movement area is equipped with fluorescence strip uniform or

high visibility vest, especially during night time or reduced visibility condition.


Batam Aero Technic issued safety notice to all personel

to use personal protective equipment including the

high visibility vest during working in the field

PENGAWASAN

KNKT.19.05.10.04 - PT.



Hasanuddin



Mei 2019

PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Angkasa Aviasi Servis 04 G 2019 10 4

KNKT recommend the Angkasa Aviasi Servis to ensure towing tractor drivers

follow the available guidance line and/or conduct briefing for any plan of

deviation maneuver from the guidance line


Angkasa Aviasi Servis amended the Ground Support

Equipment Operation SOP subchapter 5.1.1, 5.1.2 and

the Mini Briefing Form which includes requirement for

conduct briefing of pushback maneuver in every

pushback operation.

Batam Aero Technic amended the Line Maintenance

Procedure Manual to include requirement for engineer,

headsetman or wingman to have coordination with the

pushback car driver prior pushback operation.

PENGAWASAN

47

48

45



http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 042 - PK-ASE Preliminary Report.pdf

//192.168.0.9/../00 Investigation Data/2019/008 PK-EAH 16032019/Correspondence/OUT/rekomendasi segera/IK.203-1-8 KNKT 2019 (Kecelakaan Helikopter Bolkow BO 105 PK-EAH).pdf




//192.168.0.9/../02 PRELIMINARY REPORT/2019/2019 - 009 - PK-LZJ Preliminary Report.pdf







NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.19.05.10.04 - PT.



Hasanuddin



Mei 2019

PK-LZJ 25-May 2019 Preliminary Report 29-Aug 2019 Angkasa Pura I 04 B 2019 10 5KNKT recommend the PT. Angkasa Pura I to improve the surveillance ensuring

pushback operation follows the available guidance linesOPEN 27-Nov-2019 PENGAWASAN

49

KNKT.19.05.10.04 - PT.

Batik Air Indonesia

Airbus A320; PK-LZJ

Sultan Hasanuddin



25 May 2019

PK-LZJ 25-May 2019 Final Report 24-Aug 2020 Angkasa Aviasi Servis 04 G 2019 10 7

According to the Dinges et al., (1996), on 24-hour cycle, between 0200 and

0600 is estimation for window of circadian low, when human biological

functions and performance efficiency are at their lowest level. Maintaining

wakefulness during the window of circadian low has a higher potential for

fatigue and increased requirement for recovery.

The pushback operation was conducted during window of circadian low on

night time condition which might create fatigue that decreases human

alertness and increase requirement for recovery.

The reduced alertness combined with the different assumption of pushback

maneuver, focused attention to the aircraft maneuver, decreasing visual

condition, resulted in the towing tractor driver did not aware of the headset-

man position and continued the maneuver until the accident happened.

OPEN 22-Nov-2020

KNKT.19.07.14.04 -

Angkasa Aviation

Academy

Cessna 172S; PK-WUG

Cimanuk River,

Indramayu, West Java


22 July 2019

PK-WUG 22-Jul 2019 Final Report 9-Apr 2020Angkasa Aviation

Academy04 O 2019 14 1

Flying below the minimum safe altitude is contrary to the Indonesia regulation

and AAA procedure and hazardous especially if any obstacles surround the

flight path. The Garmin G1000 data log of two AAA aircraft within period of

four months prior the PK-WUG accident recorded 17 training flights flying

below the minimum safe altitude. These low flying were not detected as the

AAA had not established systems to monitor the movement of aircraft or to

review and analyze the available data, such as Garmin G1000 data log.

After the accident, the AAA installed ADS-B receiver in the Cirebon flight

operation office to enhance the capability to retrieve ADS-B data in order to

monitor the movement of aircraft in real time. The AAA had developed

Standard Operation Procedure (SOP) of flight following activities which

requires dedicated personnel to monitor flight activities using ADS-B-based

OPEN 8-Jul-2020

48

50







NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

KNKT.19.07.14.04 -

Angkasa Aviation

Academy

Cessna 172S; PK-WUG

Cimanuk River,



22 July 2019

PK-WUG 22-Jul 2019 Final Report 9-Apr 2020Angkasa Aviation

Academy04 O 2019 14 2

The AAA aircraft engineer that had suspected the aircraft had flown on low

altitude. However, the investigation did not find any air safety/hazard report

regarding this finding. The hazard that is not reported makes the absence of

risk assessment and the mitigation that may resulted in accident or incident.

KNKT recommends the AAA to improve the safety management system

implementation including hazard report by all company employees.

OPEN 8-Jul-2020

KNKT.19.07.14.04 -

Angkasa Aviation

Academy

Cessna 172S; PK-WUG

Cimanuk River,



22 July 2019

PK-WUG 22-Jul 2019 Final Report 9-Apr 2020Directorate General


The DAAO inspector used DGCA form 141-04 which comprised of several

checklist questions to check the conformity of requirement standard in the

CASR part 141. Different interpretation of the checklist guidance by DAAO

inspectors had made the requirement of the flight following did not oversight

thoroughly.

The DAAO inspectors explained that if PSC or Provisional Pilot School

Certificate holder able show the ability to monitor the aircraft in real time

during audit or surveillance, it considered complied with the flight following

requirement in the subchapter 141.27. There was no requirement to provide

evidence that the training flight was systematically monitored. Showing the

flight tracking application that able to monitor aircraft without any procedure

to conduct the flight following activities was insufficient to ensure that the

OPEN 8-Jul-2020

51

KNKT.19.12.30.04 - PT.


(Susi Air)

Cessna C208B, PK-BVN

About 32 Nm North of

Dili

On coordinate

8°5'5.71"S;

125°30'47.91"E,


5 December 2019

PK-BVN 5-Dec 2019 Preliminary Report 22-Jan 2020 Susi Air 04 O 2020 30 1

In the case of Indonesia civil aircraft experienced serious incident, the CASR

Part 830 subpart 830.06 requires person, organization or enterprise engaged in

or offering to engage in an aircraft operation, with minimum delay and by the

most suitable and quickest means available, must report to the KNKT. The

Appendix B of the CASR Part 830 described that flight crew incapacitation in

flight is included in the list examples of serious incident.

The Susi Air Safety Management System Manual (SMSM) described the

definition of serious incident, however the list of examples of serious incident

has not included. The KNKT received the report of the PK-BVN pilot

incapacitation from Indonesia Ministry of Foreign Affair five days after the

occurrence.

The delay of serious incident could affect the availability of information

OPEN 21-Apr-2020

KNKT.20.01.02.04 - PT.

Smart Cakrawala

Aviation

PK-SNP, Cessna 208B

(EX)

Kenyam Airstrip, Papua


21 January 2020

PK-SNP 21-Jan 2020 Preliminary Report 13-Mar 2020 Smart Aviation 04 O 2020 2 1

The weight and balance form of the occurrence flight described the aircraft

empty weight was not considered the additional weight of the APEs system

instalation.

The OM‐Part B stated the conversion of 1kg = 2.204622 lbs, while the Pilot’s

Operating Handbook (POH) and FAA Approved Airplane Flight Manual (AFM)

for the Cessna 208B was 1 kg = 2. 2.2046 lbs. The aircraft operator converted

the weight using 1kg = 2.2 lbs, resulted in lighter weight calculation.

The investigation conducted recalculation of the weight and balance used the

data provided in the weight and balance form of the occurrence flight. The

investigation used the aircraft empty weight of 5,401.3 lbs, considering the

aircraft had been installed with APE system and cargo pod.

The recalculation result of weight balance used the conversion of 1 kg=2.2046

OPEN 11-Jun-2020

KNKT.20.01.02.04 - PT.

Smart Cakrawala

Aviation

PK-SNP, Cessna 208B

(EX)

Kenyam Airstrip, Papua


21 January 2020

PK-SNP 21-Jan 2020 Preliminary Report 13-Mar 2020 Smart Aviation 04 O 2020 2 2

The weight and balance form of the occurrence flight used different weight

unit, the occupants and cargo weight used kg while the fuel and aircraft

weight used lbs. The difference weight unit might trigger error to the user.

Therefore, the KNKT recommends to review the weight and balance form

ensuring the calculation is used the same weight unit

OPEN 11-Jun-2020

KNKT.20.02.03.04 - PT.

Trigana Air Service

Boeing B737-300; PK-

YSG

Sentani International

Airport, Jayapura


25 February 2020

PK-YSG 25-Feb 2020 Preliminary Report 9-Apr 2020 Trigana Air Services 04 O 2020 3 1

Trigana had issued the Engineering Instruction (EI) identified by number B737-

EI/32/083R1 with the title DVI Main Landing Gear Shimmy Damper Bolt.

However, the EI did not reflect the content of Service Letter (SL) 737-SL-32-

057-E issued by the Boeing such as the inspection of the apex bolt, regularly

bleed the hydraulic manifold of the shimmy damper and define the

maintenance interval. The absence of inspection requirement to the shimmy

damper assembly might lead to the similar accident.

Therefore, KNKT recommend to implement the Boeing SL 737-SL-32-057-E (or

the latest revision) requirement.

OPEN 8-Jul-2020

KNKT.20.02.03.04 - PT.

Trigana Air Service

Boeing B737-300; PK-

YSG

Sentani International

Airport, Jayapura


25 February 2020

PK-YSG 25-Feb 2020 Preliminary Report 9-Apr 2020Directorate General


The height variation on the runway resulted in the bumpy to the aircraft

during takeoff and landing that led to increasing the vertical acceleration

during takeoff as reported by some operators. Since the height variation was

not resolve yet, the height variation on the runway might contribute to the

fatigue to the landing gear system including the torsion link and shimmy

damper.

Therefore, KNKT recommend to resolve the height variation on the runway.

OPEN 8-Jul-2020

KNKT.20.09.19.04 - PT.

Lion Mentari Airlines

Airbus A330; PK-LEG

Kualanamu


Medan


15 September 2020

PK-LEG 15-Sep 2020 Preliminary Report 18-Nov 2020Directorate General


The PIC last flight was on 16 August 2020 and last flight from right hand seat

was on 13 March 2020 while the SIC last flight was conducted on 1 February

2020. This condition was not meet the requirement for pilot recent experience

based on CASR 121.439 and Lion Air Operation Manual chapter 5.2.3.

Despite of the DGCA issued letter Number AU.402/2/22/DRJU.DKPPU-2020

related to exemption to pilot proficiency check and recent experience and

Safety Circular number SE.36 of 2020, the aircraft operator did not have any

guidance to manage this issue in their operational level. The absence of

guidance may place two pilot were not recent in a set of flight crew that may

become hazard for the flight safety.

KNKT recommend the DGCA to develop a guidance for implementing the

alleviation or required the aircraft operator to adopt the existing guidance

OPEN 16-Feb-2021

KNKT.20.09.19.04 - PT.

Lion Mentari Airlines

Airbus A330; PK-LEG

Kualanamu


Medan


15 September 2020

PK-LEG 15-Sep 2020 Preliminary Report 18-Nov 2020

Angkasa Pura II

Branch Office

Kualanamu


04 B 2020 19 2

The Angkasa Pura II had a monthly routine lawn mowing program. The

mowing area divided into several sectors. The mowing program for the sector

near the touchdown zone runway 23 was scheduled to be conducted on 24

until 30 September 2020, while the last mowing was conducted at 25 until 30

August 2020. Meanwhile, the grass on area near the runway 23 found about

50 centimeters height above the runway. This condition might increase the

possibility of water ponding and increase the hazard of runway slippery and

hydroplaning.

KNKT recommend the Angkasa Pura II to ensure the grass on the runway strip

area was maintained properly and observed/monitored in the daily routine

inspection.

OPEN 16-Feb-2021

52

53

54

50













NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI

(CLASSIFICATION)

JUMLAH 241

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