What happened
On 11 January 2007, a Casa 2/12-200 aircraft, registration PK-BRM, was conducting a charter flight from Balikpapan to Tanjung Bara, East Kalimantan. The flight, operated by PT. Aviastar Mandiri, carried 13 people, including two pilots, a maintenance engineer, and 10 passengers.
During the descent, the crew experienced a malfunction in the number-1 engine generator. Additionally, the pilot in command noted that the left engine torque was fluctuating and trending above normal parameters. Despite these technical distractions, the aircraft proceeded to its final approach to runway 04. The aircraft touched down to the right of the runway centerline and subsequently veered into soft, wet ground, striking a channel embankment and an airport perimeter fence. While the aircraft sustained substantial damage to the nose section, wings, and fuselage, all 13 occupants evacuated safely without injury.
The investigation
The investigation focused on the flight path and the crew's response to the technical issues. Investigators examined the flight data recorder and cockpit voice recorder, which revealed that the aircraft was not being flown on a stabilized approach. The investigation also looked into the aircraft's mechanical state, noting that while the power-lever anti-reverse locking system showed signs of wear, there was no evidence this contributed to the excursion. Furthermore, the investigation assessed the airport's infrastructure, noting that while runway lights were functional, the airport lacked a visual approach guidance system like VASI.
Findings
- The pilot in command conducted the landing from an unstabilized approach.
- The crew's attention was diverted by the failure of the left engine generator and fluctuating engine torque.
- The pilot in command failed to maintain effective directional control of the aircraft after touchdown.
- The aircraft's attempt to use ailerons to correct the rightward veer was ineffective.
- The aircraft veered off the runway into soft ground, leading to the impact with the embankment and fence.
Safety action
- The NTSC recommended that Aviastar Mandiri incorporate Approach-and-Landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness modules into their flight crew training programs.
- A recommendation was made to the airport operator, PT. Kalimantan Prima Coal, to install a visual approach guidance system, such as VASI, to provide better visual cues for pilots during approach.