NTSC Determined Pilot And ATC Caused Cash Of Flight RA36801 That Killed 45

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NTSC Determined Pilot And ATC Caused Cash Of Flight RA36801 That Killed 45

By Jim Douglas

December 18, 2012 - The Indonesia National Transportation Safety Committee (NTSC) has issued its final report on a Sukhoi Superjet 100 (Sukhoi RRJ-95B aircraft, registration 97004, Flight number RA 36801) that crashed on May 9, 2012, on a ridge at Mount Salak in West Java, Indonesia killing all 45 onboard.

The NTSC blames the flight crew and air traffic control. At the time of the crash poor weather conditions forced helicopters and local emergency responders to abandon their search after it had disappeared from radar during a demonstration flight.

The Sukhoi Superjet 100 was conducting a demonstration flight from Halim Perdanakusuma International Airport, Jakarta. The flight was the second of the two scheduled demonstration flights.

Occupants of the flight were 45 persons consisted of two pilots, one navigator, one test flight engineer, and 41 passengers. The passengers consisted of 4 Sukhoi Civil Aircraft Company (SCAC) personnel, one engine manufacturer (SNECMA) personnel, and 36 invited passengers (including 34 Indonesian, one American and one French nationality).

The Sukhoi Superjet 100 is a modern, fly-by-wire regional jet in the 75- to 95-seat category. With development starting in 2000, the airliner was designed by the civil aircraft division of the Russian aerospace company Sukhoi in co-operation with its main partner Boeing. Its maiden flight was conducted on May 19, 2008. On April 21, 2011, the Superjet 100 undertook its first commercial passenger flight, on the Armavia route from Yerevan to Moscow.

The flight was conducted under the Instrument Flight Rules (IFR) at an altitude of 10,000 feet. The area for the demonstration flight was planned over “Bogor” Area however the pilot may have assume that the flight was approved to 20 NM on radial 200 HLM VOR. The available charts on board the aircraft did not contain information relating to the “Bogor” Area and the nearby terrain.

The Pilot In Command acted as pilot flying while the Second In Command acted as pilot monitoring during this flight. A representative of potential customer sat on the observer seat (jump seat) in the cockpit.

At 2:20 PM local time Flight RA 36801 took off from runway 06 then turned right to intercept 200 radial from HLM VOR and climb to 10,000 feet. At 2:24 PM, the pilot contacted Jakarta Approach controller and informed ATC that the flight was established on 200 radial HLM VOR and reached 10,000 feet.

At 2:26 PM, the pilot contacted Jakarta Approach controller and requested for descent to 6,000 feet and subsequently requested to make a right turn was approved by Jakarta Approach controller. At 2:32 PM the aircraft impacted a ridge of Mount Salak on 28 NM HLM VOR on radial 198 at approximately 6,000 feet ASL. 38 seconds prior to impact, the Terrain Awareness Warning System (TAWS) audio warning “TERRAIN AHEAD, PULL UP” activated once and “AVOID TERRAIN” activated 6 times.

The PIC inhibited the TAWS system assuming that the warning was a problem on the database. Seven seconds prior to impact, the flight warning system “LANDING GEAR NOT DOWN” activated. At 2:50 PM the Jakarta Approach controller on duty noticed that the flight target disappeared on the radar monitor. There was no alert on the Jakarta Radar system prior to the disappearance of the target.

On May 10, 2012, the location of the aircraft was identified by the Search and Rescue helicopter pilot. All occupants were fatally injured and aircraft was destroyed. The Cockpit Voice Recorder (CVR) was found on May 15, 2012. The memory module was in good condition and contained 2 hours of good quality recording.

The Flight Data Recorder (FDR) was found on May 31, 2012. It contained 471 parameters of 150 hours recording time. Both recorders were downloaded in the NTSC facility by the NTSC experts and were assisted by the Russian experts. A simulation test suggested that a recovery action might have avoided the collision with terrain up to 24 seconds after the first TAWS warning.

Jakarta Radar Services had not established a minimum altitude for vectoring aircraft for certain areas and the Minimum Safe Altitude Warning (MSAW) did not provide warnings to the Jakarta Approach controller before the aircraft impacted. The investigation concluded that the factors contributing to this accident were the crew was not aware of the mountainous area surrounding the flight path due to various factors resulting in disregarding the TAWS warning. The Jakarta Radar service had not established the minimum vectoring altitudes and the system was not equipped with functioning MSAW for the particular area surrounding Mount Salak.

Distraction to the flight crew from prolonged conversation not related to the progress of the flight resulted in the pilot flying did not continue to change the aircraft heading while in orbit. Consequently, the aircraft unintentionally exited the orbit. The NTSC issued Immediate Recommendation and several Safety Recommendations to the Indonesia Directorate General of Civil Aviation (DGCA), Soekarno Hatta International Airport International Airport, Department of Aviation Industry the Ministry of Trade and Industry of Russia and Sukhoi Civil Aircraft Company of Russian Federation.