Narrative:A CASA/Nurtanio NC-212-A4 Aviocar 100 plane, registered PK-ZAI, was damaged beyond repair in an accident at Bintan Island, Indonesia. All five on board were killed.
The airplane departed from Batam-Hang Nadim Airport (BTH) at 13:18 for a test flight following an engine replacement to the engine number one. The test flight was conducted over Bintan (Tanjung Pinang) Island area. There were five persons on board consisted of two pilots, and three company engineers.
The flight climbed to the en route cruising altitude of 4000 feet, heading for Tanjung Pinang-Kidjang Airport (TNJ).
The airplane crashed nose down in the jungle at the 010 radial of the TPG VOR at a distance of about 15 NM from the VOR.
Factors contributed to the accident are as follows:
- The flight test was not properly well prepared; there was no flight test plan.
- The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine.
- The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch.
- The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades.
- The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft.
- The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action.
- The Director (DGCA) decree No 30/II/2009 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984)
» Ministry of Transportation
Follow-up / safety actions
Preliminary investigation results indicated that:
- The pilot in command was not qualified for this kind of flight;
- No permission was obtain to carry out this test flight; and
- A spare engine was carried on board during the test flight.
These findings led the DGCA to suspend the airline's AOC per February 14, 2011 as a "preventive action", according to the official statement.
NTSC issued 5 Safety Recommendations
Show all AD's and Safety Recommendations
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 Batam-Hang Nadim Airport to Tanjung Pinang-Kidjang Airport as the crow flies is 51 km (32 miles).