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5 fatalities

2011-02-12: Casa 212 Aviocar (PK-ZAI) — Sabang Merauke Raya Air Charter - SMAC — Tanjung Pinang, Indonesia

Tanjung Pinang, IndonesiaFlight

On February 12, 2011, a Casa 212 Aviocar (registration PK-ZAI) operated by Sabang Merauke Raya Air Charter - SMAC was involved in an aviation accident near Tanjung Pinang, Indonesia in flight. 5 people were killed. Investigators recorded the probable cause as: Factors contributed to the accident are as follows: • The flight test was not properly well prepared; there was no flight test plan. This summary draws on records from the Bureau of Aircraft Accidents Archives (B3A).

Sourcesthe Bureau of Aircraft Accidents Archives (B3A)Primary reportUpdated 1781195631Data APIEditorial standards

On 12 February 2011, a CASA C212-100 test flight ended in a crash on Bintan Island, killing all five on board. The aircraft disappeared from radar and was found in Gunung Kijang forest.

Accident Details

On 12 February 2011, a CASA C212-100 aircraft, registered PK-ZAI, operated by Sabang Merauke Raya Air Charter (SMAC), departed from Hang Nadim Airport, Batam at 1318 LT (0618 UTC) for a test flight following replacement of engine number one. The test flight was conducted over the Tanjung Pinang Island area. On board were two pilots and three company engineers.

At 0628 UTC, the aircraft appeared on Tanjung Pinang Approach radar display and was flying toward Tanjung Pinang. The controller informed that the aircraft was flying over Tanjung Pinang at 2000 feet. At 0633 UTC, it received clearance to climb to 4000 feet. At 0644 UTC, the aircraft disappeared from the radar display. Its last radar position was on a 16-mile radial of 010° from Tanjung Pinang Airport. The controller could not communicate with PK-ZAI.

At 0705 UTC, the controller requested relay by another aircraft to search for PK-ZAI, but other aircraft could not communicate with it. At 0706 UTC, the controller received information from the Indonesian Air Force Base at Gunung Bintan that an aircraft had crashed at Gunung Kijang forest, Bintan Island. After receiving this information, Tanjung Pinang Airport staff coordinated with the SAR Bureau, local police, and the Indonesian Army for search and rescue. The aircraft was found at Gunung Kijang forest, Bintan Island at coordinates 1° 10’ 45” N; 104° 34’ 22” E, about 30 km north of Tanjung Pinang Airport. All five occupants were fatally injured. The aircraft was substantially damaged.

Investigation

The official investigation identified the following factors contributing to the accident:

  • The flight test was not properly prepared; there was no flight test plan.
  • The current and applicable CMM is dissimilar to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirements after replacement of only one engine.
  • The left engine was shut down using normal/ground shut down procedure: fuel shut off switches off, followed by pulling the Power Lever rearward to reverse, as indicated by propeller pitch.
  • The right engine most likely shut down by windmilling prior to impact, indicated by propellers piston distance to cylinder at normal flight range position and no rotating impact on blades.
  • Casa Service Bulletin No. 212-76-07 Revision 1 (Anti Reverse), dated 23 December 1991, applicable to Casa 212-100/200, was not incorporated into this aircraft.
  • The pilot in command had paresis or paralysis of the vestibular organ or system, which could result in failure to respond normally to three-dimensional motion. This condition may increase sensitivity to Spatial Disorientation (SDO), where the pilot cannot correctly perceive position, motion, and attitude relative to the earth's horizontal or to the aircraft, creating a dangerous precondition for unsafe action.
  • Director General of Civil Aviation (DGCA) Decree No. 30/II/2000, issued 20 February 2009, requires additional medical examination items for issuing a medical certificate for pilots after their 60th birthday, including Video Nystagmography examination (differing from ICAO Doc 8984).

Probable cause

Factors contributed to the accident are as follows: • The flight test was not properly well prepared; there was no flight test plan. • The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine. • The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch. • The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades. • The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft. • The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action. • The Director (DGCA) decree No 30/II/200 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984).
Loss of control in flight

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