Descripción del Accidente ASN 06 NOV 2008 Dornier 328-110 PK-TXL - Fak Fak Airport (FKQ)
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Estado:Accident investigation report completed and information captured
Fecha:jueves 6 noviembre 2008
Hora:10:33
Tipo:Silhouette image of generic D328 model; specific model in this crash may look slightly different
Dornier 328-110
Operador:Express Air
Registración: PK-TXL
Numéro de série: 3037
Año de Construcción: 1995
Horas Totales de la Célula:24404
Ciclos:21916
Motores: 2 Pratt & Whitney Canada PW119B
Tripulación:Fatalidades: 0 / Ocupantes: 4
Pasajeros:Fatalidades: 0 / Ocupantes: 32
Total:Fatalidades: 0 / Ocupantes: 36
Daños en la Aeronave: Considerable
Consecuencias: Written off (damaged beyond repair)
Ubicación:Fak Fak Airport (FKQ) (   Indonesia)
Fase: Aterrizaje (LDG)
Naturaleza:Vuelo Doméstico Programado
Aeropuerto de Salida:Sorong-Dominique Edward Osok Airport (SOQ/WAXX), Indonesia
Aeropuerto de Llegada:Fak Fak Airport (FKQ/WASF), Indonesia
Número de Vuelo:XN9000
Descripción:
A Dornier 328-110 passenger plane, registered PK-TXL and operated by Express Air, sustained substantial damage during a hard landing at Fak Fak Airport (FKQ), Indonesia.
Express Air flight 9000 left Sorong (SOQ) at 09:58 local time on a domestic flight to Fak-Fak (FKQ). The Pilot in Command was the flight instructor and was also pilot monitoring during the flight. The First Officer was the handling pilot from the left seat. He was undergoing command training on the aircraft type. Another First Officer (FO2) was located in the observer seat in the cockpit.
The aircraft descended suddenly and rapidly when it was on short final approach. About 65 seconds before ground impact, the RPM of both propellers commenced to decrease to approximately 70%. Propeller RPM then suddenly reduced, followed by an immediate and rapid increase of propeller RPM to 111% left and 97% right, then just as sudden and rapid, the left propeller RPM reduced to 77% and the right to 80%.
It is likely that an attempted corrective action was made by the PIC. However, it was too late to prevent the aircraft from touching down before the end of the runway. The aircraft touched down heavily approximately 5 meters before the touch-down area of runway 10. It struck the raised lip of the runway causing the left main gear to collapse. It stopped on the runway, approximately 500 meters from the touch-down area.

The investigators found that the aircraft operator did have a robust crew resource management (CRM) implementation training program and did not have a Line Operations Safety Audit (LOSA) program. Also, there was no evidence that any of the pilots had completed any form of CRM training for more than 9 years.
And other than the handling pilot, there was no evidence that the pilots had completed ALAR/CFIT training.

Probable Cause:

CAUSES:
The Digital Flight Data Recorder data showed evidence that the aircraft descended suddenly and rapidly when it was on short final approach before the aircraft was above the touch-down area. Propeller RPM was reduced suddenly and rapidly to 70% less than 10 seconds before ground contact. Given that the propellers are constant speed units, the sudden and rapid changes could not be explained other than the probability that a crew member had made the control inputs.
The PIC (pilot monitoring/flight instructor) did not monitor the operation of the aircraft sufficiently to ensure timely and effective response to the pilot induced excessive sink rate.
Other Factors:
The airport did not meet the ICAO Annex 14 Standard with respect to the requirement to have runway end safety areas.

Accident investigation:

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Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 165 days (6 months)
Accident number: KNKT/08.26/09.02.39
Download report: Final report


Subsiguiente / acciones de seguridad
The undershoot area before the end of the runway was 30 cm lower than the surface of the runway. Following the accident the Fak Fak airport authority raised the level of the undershoot area to the same level as the runway.

NTSC issued 10 Safety Recommendations

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Fotos

photo of Dornier-328-110-PK-TXL
accident date: 06-11-2008
type: Dornier 328-110
registration: PK-TXL
 

Video, social media

Map
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 Sorong-Dominique Edward Osok Airport to Fak Fak Airport as the crow flies is 249 km (156 miles).
Accident location: Exact; deduced from official accident report.

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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