Accident description
Last updated: 28 July 2014
Status:Final
Date:Thursday 29 September 2011
Time:07:50
Type:CASA/Nurtanio NC-212 Aviocar 200
Operator:Nusantara Buana Air
Registration: PK-TLF
C/n / msn: 283/88N
First flight: 1989
Total airframe hrs:11348
Cycles:13646
Engines: 2 Garrett TPE331-10R-521C
Crew:Fatalities: 2 / Occupants: 2
Passengers:Fatalities: 16 / Occupants: 16
Total:Fatalities: 18 / Occupants: 18
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:30 km (18.8 mls) E of Kutacane-Alas Leuser Airport (   Indonesia) show on map
Phase: En route (ENR)
Nature:Domestic Non Scheduled Passenger
Departure airport:Medan-Polonia Airport (MES/WIMM), Indonesia
Destination airport:Kutacane-Alas Leuser Airport, Indonesia
Flightnumber: 823
Narrative:
A CASA/Nurtanio NC-212 Aviocar 200 passenger plane was damaged beyond repair in an accident near Bohorok, Sumatra, Indonesia. All 16 passengers and two crew members were killed.
The aircraft departed from Medan, Indonesia at 07:28 on a domestic flight to Kutacane. The estimated time of arrival was 07:58. The flight was conducted under the Visual Flight Rules (VFR).
At 07:32 the aircraft contacted the Medan Director controller and reported passing 4000 and climbing to 8000 feet. The estimated time of arrival at Kutacane was revised to 07:50 and the pilot requested to fly direct to point "PAPA".
At about 07:41 the crew attempted to established radio contact with Kutacane, but there was no reply. Radar contact was lost at 07:50. The wreckage was spotted in a forest on a mountainside at an elevation of 5055 feet. A rescue party arrived at the scene on October 1, finding that all aboard had died.


FACTORS:
1. The flight was in VFR however both pilots agreed to fly into the cloud, consequently, the flight crew had lack of situation awareness due to loss of visual references to the ground and no or late recovery action prior to impact due to low visibility.
2. There was lack of good crew coordination due to steep cockpit transition gradient.
3. There was no checklist reading and crew briefing.

Classification:
Controlled Flight Into Terrain (CFIT) - Mountain

Sources:
» Metro TV News
» Kompas
» Indonesian Ministry of Transport

Official accident investigation report
investigating agency: National Transportation Safety Committee (NTSC) - Indonesia
report status: Final
report number: KNKT.11.09.20.04
report released:20-JUL-2013
duration of investigation:660 days (1 year 9.8 months)
download report: CASA 212-200 PK-TLF Leuser Mountain National Park, North Sumatera Republic of Indonesia 29 September 2011 (NTSC KNKT.11.09.20.04)
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Follow-up / safety actions

NTSC issued 1 Safety Recommendation

Show all AD's and Safety Recommendations

Photos

photo of CASA/Nurtanio NC-212 Aviocar 200 PK-TLF
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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 Medan-Polonia Airport to Kutacane-Alas Leuser Airport as the crow flies is 91 km (57 miles).

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CASA 212

  • 81st loss
  • 477+ built
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 Indonesia
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