Status: | Accident investigation report completed and information captured |
Datum: | Montag 18 Juni 2018 |
Zeit: | 14:52 |
Flugzeugtyp: |  Cessna 208B Grand Caravan |
Fluggesellschaft: | Spirit Avia Sentosa |
Kennzeichen: | PK-FSL |
Werknummer: | 208B1254 |
Baujahr: | 2007 |
Betriebsstunden: | 11276 |
Anzahl Zyklen der Zelle: | 15519 |
Triebwerk: | 1 Pratt & Whitney Canada PT6A-114A |
Besatzung: | Todesopfer: 0 / Insassen: 2 |
Fluggäste: | Todesopfer: 0 / Insassen: 11 |
Gesamt: | Todesopfer: 0 / Insassen: 13 |
Sachschaden: | schwer beschädigt |
Konsequenzen: | Repaired |
Unfallort: | 6,7 km (4.2 Meilen) E of Nabire Airport (NBX) ( Indonesien)
|
Flugphase: | Annäherung (APR) |
Betriebsart: | Inländischer außerplanmäßiger Passagierflug |
Flug von: | Bilogai/Sugapa Airport (ZGP/WAYB), Indonesien |
Flug nach: | Nabire Airport (NBX/WABI), Indonesien |
Unfallbericht:The Spirit Avia Sentosa Cessna 208B was conducting unscheduled passenger flights. The flights of the day planned for the pilots were from Douw Aturure Airport (WABI), Nabire to Sugapa Airstrip (WAYB) and return for three times. The PIC acted as Pilot Flying (PF) and the SIC acted as Pilot Monitoring (PM) on all these flights.
After the third flight from Nabire to Bilorai, the aircraft landed safely at Sugapa Airstrip. Prior to the departure to Nabire, there was no report or record of aircraft system malfunction and the aircraft was operated within the approved weight and balance envelope. On board the aircraft were two pilots and 11 passengers.
The aircraft departed from in daylight conditions and cruised at an altitude of 10,500 feet. The aircraft was flying in an out through clouds when approaching Nabire.
Over checkpoint BRAVO, the pilot made initial contact with Nabire Tower controller and advised that the aircraft was descending and passed altitude of 6,600 feet.
During descent after checkpoint BRAVO, the pilot noticed development of clouds along the route and decided to avoid the clouds by deviating the aircraft track to the right of the GPS route.
At about 4.5 Nm from NBR VOR/DME, the flight monitoring system of the Spirit Avia Sentosa recorded the aircraft altitude was 2,000 feet.
The PM noticed yellow on the aircraft GPS which meant the terrain was between 1,000 feet and 100 feet below the aircraft altitude and advised the PF. The PF decided to disengage the auto pilot, reduced the rate of descend and continued to get visual reference on ground.
The PM noticed an "X" symbol on the GPS which indicated a potential impact point and advised the PF. The PF was continuing the descent and then the second "X" appeared on the GPS. A few second later, the PF noticed terrain ahead and pulled the aircraft. The left side of the aircraft impacted a tree.
At about 2 Nm, the pilot advised the controller of the aircraft position and requested to make a landing approach using runway 16. The controller approved the pilot request. The rest of the flight was uneventful and the aircraft landed safely using runway 16 at Nabire.
No one injured in this occurrence and the aircraft was substantially damaged. Evidence of impact marks were found on the left side of the aircraft which were on the main landing gear strut, wing strut fairing, wing and horizontal stabilizer
Probable Cause:
The KNKT concluded the contributing factors as follows:
- The VFR weather minimum requirement that was not implemented properly made the pilot did not have clear visual of the surrounding area.
- The consideration of less risk of flying into clouds and relying to the GPWS's aural alert or having visual contact to the terrain, resulted in the ignorance to the GPS alert and continuation of the descend while flying into clouds.
Accident investigation:
|
Investigating agency: | NTSC Indonesia  |
Status: | Investigation completed |
Duration: | 2 years and 10 months | Accident number: | KNKT.18.06.24.04 | Download report: | Final report
|
|
Sicherheitsempfehlungen
NTSC issued 7 Safety Recommendations
Issued: -- | To: Spirit Avia Sentosa | 04.O-2018-24.1 |
KNKT recommends the FlyingSAS to ensure the route guidance for pilot contains same information. |
Issued: -- | To: AirNav Indonesia | 04.O-2018-24.2 |
KNKT recommends the AirNav Indonesia to provide correct information of the NBR VOR/DME location to the DGCA and also review the possibility of other incorrect coordinate of navigation aid prior to publish in the AIP |
Issued: -- | To: DGCA Indonesia | 04.O-2018-24.3 |
KNKT recommends the DGCA to ensure that the safety recommendation number 04.R-2015-17.6 which published in 2017 is performed for all Indonesian airports without instrument approach procedure. |
Issued: -- | To: DGCA Indonesia | 04.O-2018-24.4 |
KNKT recommends the DGCA to determine the correct coordinate of NBR VOR/DME and also review the possibility of other incorrect coordinate of navigation aid in the AIP. |
Issued: -- | To: Spirit Avia Sentosa | 04.O-2018-24.5 |
KNKT recommends the FlyingSAS to ensure all pilot taking into account the GPS information as additional reference for the decision making. |
Issued: -- | To: Spirit Avia Sentosa | 04.O-2018-24.6 |
KNKT recommends the FlyingSAS to ensure the current publication of VFR routes in the AIP includes the altitude restriction were adopted in the FlyingSAS flight guidance. |
Issued: -- | To: Spirit Avia Sentosa | 04.O-2018-24.7 |
KNKT recommends the FlyingSAS to review the operational control system to improve the operational control and supervision for ensuring the flight operation is conducted in safe and efficient manner. |
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Fotos

accident date:
18-06-2018type: Cessna 208B Grand Caravan
registration: PK-FSL

accident date:
18-06-2018type: Cessna 208B Grand Caravan
registration: PK-FSL

accident date:
18-06-2018type: Cessna 208B Grand Caravan
registration: PK-FSL
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 Bilogai/Sugapa Airport to Nabire Airport as the crow flies is 175 km (109 miles).
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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