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PenerbanganFinal ReportAccident

DHC 4 Caribou PK-SWW — 5 Nm east of Ilaga Pass, Papua

Nomor investigasi
KNKT.16.10.38.04
Waktu kejadian
Lokasi
5 Nm east of Ilaga Pass, Papua
Wilayah administratif
PUNCAK, PAPUA

Kronologi & deskripsi kejadian

The aircraft departed from Timika to the intended destination of Ilaga, the aircraft crashed near Ilaga Pass

Data teknis

Data teknis kejadian DHC 4 Caribou PK-SWW — 5 Nm east of Ilaga Pass, Papua
Operator / maskapaiPerkumpulan Penerbangan Alfa Indonesia
RegistrasiPK-SWW
Tipe pesawatDHC 4 Caribou
MTOWabove 5,700 kg
Tipe operasiOC 91
Fase penerbanganCRS
Jenis kejadianControlled Flight into Terrain
TeritoriPAPUA

Korban

Meninggal4orang

Faktor penyebab & kontributor

Faktor I
E
Faktor II
H
Faktor III
T

Sarana & operator terkait

Daftar sarana dan operator yang terlibat
OperatorFlight NumberRegistrasiTipe PesawatMtowTahun PembuatanTipe Operasi
Perkumpulan Penerbangan Alfa Indonesia—PK-SWWDHC 4 Caribouabove 5,700 kg—OC 91

Rekomendasi keselamatan yang diterbitkan

Penerima: Directorate General of CivilRegulator Indonesia

  • 04.R-2016-81.04OPEN0 tanggapan

    During the investigation, it was found that the CVR CAM channel was covered by the engine noise and the voice in the cockpit could not be heard. The other station communication and aircraft system alert or warning sound were not recorded in the CVR. The review to the wiring design found that the CVR wiring interconnection had caused in the improper CVR recording. The improper CVR recording was in…

    Lihat butir & lini masa tanggapan

Penerima: Directorate General of Civil AviationRegulator Indonesia

  • 04.O-2016-81.02OPEN0 tanggapan

    The TAWS or EGPWS terrain database in Papua area mostly provided in low resolution. The low-resolution terrain database resulted in un-necessary caution or warning whenever the aircraft flies to the mountainous area even though the flight able to be conducted safely. The pilot tends to inhibit or deactivate the TAWS or EGPWS system to avoid the un-necessary caution or warning. The flight with inac…

    Lihat butir & lini masa tanggapan

Penerima: Directorate General of Civil AviationRegulator Indonesia

  • 04.R-2016-81.03OPEN0 tanggapan

    The test result of the modification of the aircraft by the installation of CVR, TAWS or other system after the aircraft had been modified were not available. The absence of the modification test result made the successful installation and functionality of the systems could not be ascertained. The investigation found that the voice that should be recorded on the CAM channel was covered by engine no…

    Lihat butir & lini masa tanggapan

Penerima: Pen Turbo Aviation Inc., USAOperator Pesawat

  • 04.MO-2016-81.05OPEN0 tanggapan

    After completion of the modification, the investigation revealed that in the modified CVR wiring system of the aircraft, the microphones lines of the SIC, PIC and spare line, were directly hooked to the channel 1 (SIC), 2 (PIC) and 3 (spare) of CVR audio line respectively. As the result, the incoming audio communication and other audio which generated by the aircraft system were not accommodated i…

    Lihat butir & lini masa tanggapan

Penerima: Perkumpulan Penerbangan Alfa IndonesiaOperator Pesawat

  • 04.O-2016-38.01OPEN0 tanggapan

    According to factual information and initial findings, the Komite Nasional Keselamatan Transportasi (KNKT) recommend to Perkumpulan Penerbangan Alfa Indonesia to comply the DGCA Safety Circular number SE.24 of 2016.

    Lihat butir & lini masa tanggapan

Penerima: Perkumpulan Penerbangan Alfa IndonesiaOperator Pesawat

  • 04.O.2016.38-06CLOSED1 tanggapan

    During the flight, the PIC communicated with another aircraft pilot stated that the aircraft ‘was diving’ which can be assumed that the aircraft was flying in the cloud. The CASR Part 91.155 Basic VFR Weather Minimums, restricts the pilot to maintain certain distance with the cloud during flying in VFR flight. Flying in the cloud during VFR flight reduces the pilot awareness to the surrounding te…

    Lihat butir & lini masa tanggapan

Penerima: Perkumpulan Penerbangan Alfa IndonesiaOperator Pesawat

  • 04.O.2016.38-07TDTL1 tanggapan

    The TAWS or EGPWS terrain database in Papua area mostly provided in low resolution. The low-resolution terrain database resulted in un-necessary caution or warning whenever the aircraft flies to the mountainous area even though the flight able to be conducted safely. The pilot tends to inhibit or deactivate the TAWS or EGPWS system to avoid the un-necessary caution or warning. The flight with inac…

    Lihat butir & lini masa tanggapan

Penerima: Perkumpulan Penerbangan Alfa IndonesiaOperator Pesawat

  • 04.O.2016.38-08TDTL1 tanggapan

    During the investigation, it was found that the CVR CAM channel was covered by the engine noise and the voice in the cockpit could not be heard. The other station communication and aircraft system alert or warning sound were not recorded in the CVR. The review to the wiring design found that the CVR wiring interconnection had caused in the improper CVR recording. The improper CVR recording was in…

    Lihat butir & lini masa tanggapan