What happened
On 26 January 2008, a Casa 212-20 and0 aircraft, registration PK-VSE, was performing a cargo charter flight from Tarakan to Long Apung in East Kalimantan, Indonesia. The flight, operated by PT. Dirgantara Air Service, was carrying two pilots and one engineer/load master.
During the approach to Long Apung Airport, the aircraft was maneuvering on the downwind leg of the runway 35 circuit. At this time, the area was obscured by low-hanging clouds. Cockpit voice recordings reveal that the copilot issued two warnings to the pilot in command regarding an approaching hill. Shortly after these warnings, the aircraft struck trees and terrain at an elevation of 2,766 feet. The impact was non-survivable, and all 3 occupants were killed.
The investigation
The investigation conducted by the NTSC focused on the flight conditions and crew actions during the final approach. Investigators analyzed the cockpit voice recorder, which provided clear audio of the crew's final moments. The data showed no evidence of mechanical failure or in-flight fire prior to the impact. However, the investigation noted that the cargo within the aircraft had not been properly secured, leading to movement during the crash.
Findings
- The aircraft was in an airworthy condition at the time of departure.
- The crew was flying under visual flight rules (VFR) but inadvertently entered instrument meteorological conditions (IMC) due to low cloud cover.
- The pilots failed to maintain the runway in sight during the downwind leg of the circuit.
- The pilots continued flight into instrument meteorological conditions below the minimum safe altitude.
- The crew lacked sufficient awareness of the aircraft's proximity to the terrain until the collision was imminent.
Safety action
The NTSC recommended that PT. Dirgantara Air Service review its pilot training and checking procedures. Specifically, the committee advised incorporating Flight Safety Foundation (FSF) materials regarding Approach-and-landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness into their recurrent training programs.