ASN Aircraft accident Boeing 737-230 PK-RIM Medan-Polonia Airport (MES)
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Status:Accident investigation report completed and information captured
Date:Monday 5 September 2005
Type:Silhouette image of generic B732 model; specific model in this crash may look slightly different
Boeing 737-230
Operator:Mandala Airlines
Registration: PK-RIM
MSN: 22136/783
First flight: 1981-07-20 (24 years 2 months)
Total airframe hrs:51599
Engines: 2 Pratt & Whitney JT8D-15
Crew:Fatalities: 5 / Occupants: 5
Passengers:Fatalities: 95 / Occupants: 112
Total:Fatalities: 100 / Occupants: 117
Ground casualties:Fatalities: 49
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:Medan-Polonia Airport (MES) (   Indonesia)
Crash site elevation: 35 m (115 feet) amsl
Phase: Initial climb (ICL)
Nature:Domestic Scheduled Passenger
Departure airport:Medan-Polonia Airport (MES/WIMM), Indonesia
Destination airport:Jakarta-Soekarno-Hatta International Airport (CGK/WIII), Indonesia
Flightnumber: 091
Mandala Airlines flight 091, a Boeing 737-200 was to depart Medan-Polonia Airport (MES) for Jakarta-Soekarno-Hatta International Airport (CGK). The previous flight was from Jakarta and arrived at Medan uneventfully. The same crew have flight schedule on the same day and returned to Jakarta.
At 09:52 local time, MDL 091 asked for push back and start up clearance. After receiving the approval the air traffic controller the crew began starting the engines.
At 09:56, the controller cleared MDL 091 to taxi into position on runway 23 via taxiway Alpha. Six minutes later MDL 091 received clearance for take off with additional clearance from ATC to turn left heading 120° and maintain 1500 ft.
The airplane failed to become airborne and overran runway 23, impacting several approach lights. It traveled through a grass area and over a river, and impacted several buildings and vehicles before coming to rest on a road. A post crash fire destroyed much of the airplane.
One hundred passengers and crew members on board the plane died. Fifteen passengers seriously injured and two passengers (a mother and child) survived without any injuries. 49 persons on ground were killed and 26 people were seriously injured.
Medan-Polonia has a single 2900 x 45 meters asphalt runway (05/23).

Probable Cause:

The National Transportation Safety Committee determines that probable causes of this accident are:
- The aircraft took-off with improper take off configuration namely with retracted flaps and slats causing the aircraft failed to lift off.
- Improper checklist procedure execution had lead to failure to identify the flap in retract position.
- The aircraft’s take off warning horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning horn was not sounding.

Accident investigation:

Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 3 years and 4 months
Accident number: KNKT/05.24/09.01.38
Download report: Final report

Wrong takeoff configuration (flaps/trim)
Loss of control

» SKYbrary 
» Antara
» Reuters
» Jakarta Post

Follow-up / safety actions

NTSC issued 8 Safety Recommendations

Show all...


photo of Boeing-737-230-PK-RIM
accident date: 05-09-2005
type: Boeing 737-230
registration: PK-RIM
photo of Boeing-737-230-TF-ABY
accident date: 05-09-2005
type: Boeing 737-230
registration: TF-ABY

Aircraft history
date registration operator remarks
20 JUL 1981 D-ABHK Lufthansa
29 APR 1994 TF-ABY Air Atlanta Icelandic/Tunisair
21 OCT 1994 D-ABHK Lufthansa returned
24 NOV 1994 PK-RIM Mandala Airlines

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Medan-Polonia Airport to Jakarta-Soekarno-Hatta International Airport as the crow flies is 1388 km (867 miles).
Accident location: Approximate; accuracy within a few kilometers.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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Boeing 737-200

  • 1114 built
  • 102nd loss
  • 51st fatal accident
  • The worst accident
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  • 2nd worst accident (at the time)
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