No fatalities

2011-12-20: Boeing 737-300 (PK-CKM) — Sriwijaya Air — Yogyakarta, Indonesia

Yogyakarta, IndonesiaLanding (descent or approach)

On December 20, 2011, a Boeing 737-300 (registration PK-CKM) operated by Sriwijaya Air was involved in an aviation accident near Yogyakarta, Indonesia during landing or approach. No fatalities were reported. Investigators recorded the probable cause as: Findings: 1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight. 2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation. 3. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A); 16 related events involving the same aircraft type or operator are linked below.

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781195088Data APIEditorial standards
Boeing 737-300
Photo: San Diego Air & Space Museum Archives / Public domain, via Wikimedia Commons

On 20 December 2011, Sriwijaya Air Flight 230, a Boeing 737-300, overran the runway after landing at Adisutjipto International Airport. The aircraft sustained major damage; six passengers reported minor injuries.

Flight History

On 20 December 2011, a Boeing 737-300 aircraft, registered PK-CKM, operated by PT. Sriwijaya Air as flight SJ230 from Soekarno Hatta International Airport, Jakarta, to Adisutjipto International Airport, Yogyakarta. The aircraft carried 141 persons: two pilots, four cabin crew, and 135 passengers (124 adults, 7 children, 4 infants). Departure from Jakarta was at 14:00 local time (07:00 UTC). The pilot in command (PIC) served as pilot flying, and the co-pilot as pilot monitoring.

At 08:10 UTC, the aircraft held 8 NM from JOG VOR due to bad weather. After a second holding, weather deteriorated further, leading the airport authority to close the airport for takeoffs and landings. The pilot requested a diversion to Juanda Airport, Surabaya, and landed there at 08:40 UTC. After refueling and receiving information about weather improvement in Yogyakarta, the aircraft departed again at 09:20 UTC. For this segment, the PIC again acted as pilot flying. The aircraft now had 137 persons on board: two pilots, four cabin crew, and 131 passengers (120 adults, 7 children, 4 infants).

Approach and Landing

While approaching Adisucipto Airport, the aircraft was fifth in a sequence of seven aircraft. Passing JOG VOR, radar showed airspeed of 203 knots at 2,700 feet. The approach controller instructed the crew to reduce speed. At approximately 1,200 feet, the pilots had the runway in sight and disengaged the autopilot and autothrottle. The PIC made corrections to the approach profile, including a bank angle up to 25 degrees and a rate of descent up to 2,040 feet per minute. The GPWS activated "pull up" and "sink rate" warnings.

The aircraft touched down at 156 knots, compared to a target landing speed of 138 knots. During the landing roll, the autobrake and spoilers activated automatically. Thrust reversers were deployed, and FDR data showed N1 increased and decreased to idle before increasing to 80% prior to the aircraft stopping. The PIC determined the aircraft could not stop on the runway and turned left. The aircraft came to a stop 75 meters from the end of runway 09 and 54 meters left of the centerline.

Evacuation and Damage

Most passengers evacuated via the left and right forward escape slides. All passengers evacuated safely; a passenger on a stretcher was evacuated by airport rescue. Six passengers reported minor injuries; all crew and remaining passengers were uninjured. The aircraft sustained major damage to the right main and nose wheel.

Investigation Findings

The official investigation noted that the aircraft was airworthy with no evidence of malfunction. Crew licenses and medical certificates were valid with no evidence of incapacitation. The flight crew did not conduct an approach crew briefing, and no checklist was read. The PIC did not have the instrument approach procedure immediately available. During approach, the PIC's course indicator was set at 091 and the SIC's at 084. Rate of descent varied, reaching up to 1,920 feet per minute, and below 500 feet AGL up to 2,040 feet per minute. The approach did not meet stabilized approach criteria per the FCOM. Several GPWS warnings occurred. Touchdown speed was 156 knots, followed by a bounce. Flaps extended to 40 after touchdown. FDR showed N1 reduction during thrust reverser activation. Crew resource management was not well implemented. Factors identified included unsuccessful recognition of fixation and complacency, which affected the pilot's decision to land despite an unstabilized approach.

Probable cause

Findings: 1. The aircraft was airworthy prior the accident. There was no evidence that the aircraft had malfunction during the flight. 2. The crew had valid license and medical certificate. There was no evidence of crew incapacitation. 3. In this flight Pilot in Command acted as Pilot Flying and Second In command acted as Pilot Monitoring. 4. The flight crew did not conduct approach crew briefing. 5. There was no checklist reading. 6. The PIC as Pilot Flying did not have the instrument approach procedure immediately available to review during approach. 7. During the approach, the PIC course indicator was set at 091 and the SIC was at 084. 8. The rate of descend recorded vary and up to 1920 ft per minute and below 500 ft AGL the rate of descend recorded up to 2040 ft per minute. 9. The approach did not meet the stabilize approach criteria as stated in the FCOM. 10. There were several GPWS warning of ‘sink rate’ and ‘pull up’ activated during approach. 11. The aircraft touched down at speed 156 Kt before bounced, instead of 138 Kt target landing speed. 12. The flap extended to 40 after the aircraft touch down. 13. The FDR recorded reduction in N1 during thrust reverser activation after landing. 14. The CRM was not well implemented. Factors: Unsuccessful to recognize the two critical elements, namely fixation and complacency affected pilot decision to land the aircraft while the approach was not meet the criteria of stabilized approach.