| Estado: | Final |
| Fecha: | 06 NOV 2008 |
| Hora: | 10:33 |
| Tipo: | 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 |
| 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: | 9000 |
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.
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.
Fuentes:
» Express Air plane crash-lands in Fakfak (The Jakarta Post 7-11-2008)
» Express Air Belum Disingkirkan (Kompas 6-11-2008)
Official accident investigation 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
| Issued: -- | To: Express Air | PK-TXL (1) |
| The National Transportation Safety Committee recommends that Express Air ensure that all company pilots are given Crew Resource Management (CRM) training, including the implementation of specific CRM aspects relating to the operation of aircraft being flown by the crew. For example the pilots in the Fak Fak occurrence should be given CRM implementation training specifically relating to the Dornier 328-100 aircraft. |
| Issued: -- | To: Torea Airport, Fak-Fak, Papua operator | PK-TXL (10) |
| The National Transportation Safety Committee recommends that the Torea Airport operator review the procedures and equipment for the airport Rescue and Fire Fighting Services to ensure that they:
- meet the minimum requirements specified in the International Civil Aviation Organization’s Annex 14. |
| Issued: -- | To: Express Air | PK-TXL (2) |
| The National Transportation Safety Committee encourages the use of the Flight Safety Foundation (FSF) Approach-and-landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness material and recommends that Express Air include ALAR and CFIT awareness modules in their recurrency training programs, and conduct initial ALAR and CFIT training for flight crew members who have not yet completed such training. |
| Issued: -- | To: Express Air | PK-TXL (3) |
| The National Transportation Safety Committee recommends that Express Air implement a Line Operations Safety Audit (LOSA) program. |
| Issued: -- | To: DGCA Indonesia | PK-TXL (4) |
| The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation, as part of its safety audit/surveillance oversight of Express Air, assess the adequacy of Express Air’s CRM training program, in particular CRM implementation. |
| Issued: -- | To: DGCA Indonesia | PK-TXL (5) |
| The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the Torea Airport, Fak-Fak, Papua runway complex to ensure that runway end safety areas (RESA) are established that meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14. |
| Issued: -- | To: DGCA Indonesia | PK-TXL (6) |
| The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) ensure that the operator of Torea Airport, Fak-Fak, Papua surveys the Torea Airport runway complex and ensure that the runway dimensions promulgated on aerodrome charts are accurate. |
| Issued: -- | To: DGCA Indonesia | PK-TXL (7) |
| The National Transportation Safety Committee recommends that the Directorate General of Civil Aviation (DGCA) review the procedures and equipment used by the Toera Airport, Fak Fak, Papua, Rescue and Fire Fighting Services to ensure that they:
- meet the minimum requirements specified in the International Civil Aviation Organization’s Annex 14. |
| Issued: -- | To: Torea Airport, Fak-Fak, Papua operator | PK-TXL (8) |
| The National Transportation Safety Committee recommends that the operator of Torea Airport, Fak-Fak, Papua survey the runway complex and ensure that the runway dimensions promulgated on aerodrome charts are accurate. |
| Issued: -- | To: Torea Airport, Fak-Fak, Papua operator | PK-TXL (9) |
| The National Transportation Safety Committee recommends that the operator of Torea Airport, Fak-Fak, Papua review the runway complex to ensure that runway end safety areas (RESA) are established that meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14. |
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