Investigators are stumped when a turboprop crashes into an Indonesian mountaintop.
Trigana Air Flight 267 was a scheduled passenger flight from Sentani to Oksibil in the eastern Indonesian province of Papua. On 16 August 2015, the ATR 42 turboprop operating the service crashed on approach in the Bintang highlands region of Oksibil, killing all 49 passengers and 5 crew members
With 54 deaths, it is the deadliest accident involving the ATR 42, and the airline's deadliest accident since its establishment in 1991.
The Indonesian National Transportation Safety Committee published its final report into the accident in December 2017.Deviation from visual approach guidance and visual flight rules without regard to weather and terrain, and the likely deactivation of the EGPWS system contributed directly to the crash, compounded by shortcomings in Trigana Air's safety culture
The Trigana Air flight took off from Sentani Airport in Jayapura at 14:22 WIT (UTC+9, 05:22 UTC) and was expected to land in Oksibil at about 15:04.(vii) Oksibil is a remote town near the country's border with Papua New Guinea. Oksibil Airport did not have an instrument landing system to guide aircraft in to land because it is located close to a mountain.
Contact was lost with the aircraft at about 14:55. No distress call was made by the crew.(p8) The crew had been expected to make contact with ground staff at Oksibil Airport at around 15:00; attempts by those at the airport to contact the aircraft were unsuccessful.At the time of the accident, the aircraft was on the final section of its scheduled route.
Weather conditions
Conflicting statements regarding the weather conditions were released. Stormy weather was initially cited as a possible cause of the crash,[failed verification] however it was later confirmed that the weather was good. Minister of Transportation Ignasius Jonan stated that bad weather was not the cause of the crash. Data from the local Indonesian Agency for Meteorology, Climatology and Geophysics office showed that the weather at the time of the crash was sunny. The crew of another aircraft landing prior to the crash also reported conditions at the time as "good".[The Ministry of Transportation acknowledged that Indonesia's air navigation system equipment was very outdated and dated back to the 1950s, especially in remote areas such as Papua. Most airports in Papua did not have modern navigation aids at the time. Without this equipment, the airports and flight crew must rely on visual flight rules.
Passengers and crew
The aircraft was carrying 49 passengers and 5 crew members. The passenger manifest released by Trigana Air indicated all on board were Indonesian. There were 44 adults, 3 children and 2 infants among the passengers. There were two pilots; Captain Hasanuddin (aged 60) had joined Trigana in 2000, he had 25,200 hours of total flying experience and 7,300 hours' experience flying ATR 42s. First Officer Aryadin Falani (aged 44) had joined Trigana in 2008 and had a total of 3,800 hours flying experience, of which 2,600 were in flying ATR 42s.
Among the passengers were four postal servicemen heading to Oksibil to distribute the Indonesia Sejahtera card, a programme for the poor that President Joko Widodo developed and promoted while campaigning for the 2014 Indonesia Presidential Election.They were reportedly carrying around 6.5 billion rupiah ($US470,000).Three local government officials and two members of the Regional Representatives Council were also on board to attend celebrations in Oksibil for the 70th anniversary of Indonesia's independence.
Investigation
The Indonesian National Transportation Safety Committee (NTSC or KNKT) opened an investigation to the crash. In line with international regulations, as the aircraft was built in France, its Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) participated, sending three investigators. Aircraft manufacturer ATR also assisted and sent four technical advisers.
The flight manifest released by Trigana was found to be wrong, being for another Trigana flight. As a result, the Chairman of Sentani Airport was fired by the Transportation Ministry. Sixteen workers were also investigated by the police because of their involvement.Two of Trigana's staff remained in custody.[needs update] Ignasius Jonan, Indonesian Minister of Transportation, criticized the airport staff saying the situation was a "big mess" and needed to be cleaned up.
The Flight Data Recorder had a history of maintenance problems going back more than a year, and was inoperative at the time of the accident. Instead, investigators rebuilt the predicted flight path of Flight 267 using Google Earth and data from the CVR and its spectrum analysis.(pp18-19) The analysis of the CVR revealed that at 14:55 local time, the flight crew of Flight 267 stated their intention to make a direct left base. Immediately after that, Flight 267 deviated from the standard approach path.
Flight 267 deviated to the right. The area on the right side of Flight 267 was surrounded by mountainous terrain. Some of the terrain was as high as 8,000 ft. In addition, Papua's unpredictable weather would endanger the flight easily. Pilots had reported that fog sometimes "came out of nowhere", which could limit the pilot's visibility. Though good weather conditions were reported in the area, localized fog existed in the mountains.[failed verification] According to the NTSC, based on the CVR analysis, Flight 267 descended while in the clouds, while the mountains were covered in fog.[8](p44) As the aircraft was flying too low to pass through the mountain range, the NTSC concluded that it was plausible that the aircraft's proximity to terrain was not noticed by the flight crew.
The investigation team analyzed the crew's motivation to deviate from the standard approach and observed that, on the crew's previous flight from Sentani to Oksibil earlier the same day, they did exactly the same thing: joining directly on left base.(pp43-45) Investigators then stated that the crew may have been overconfident with their flying skill. Due to their previous success on landing an aircraft prior to the accident (by flying below the minimum safe altitude), the crew may have believed that they would be able to conduct a similar maneuver without adverse consequences. The crew had accrued thousands of flight hours and were familiar with the airport.
The NTSC noted that the EGPWS did not sound during the flight's final moments, even though Flight 267 was going to hit the mountain. Investigators discovered that the circuit breaker responsible for the activation of the EGPWS had intentionally been pulled by Flight 267's crew. Trigana Air's management stated that some pilots claimed the warnings sometimes sounded improperly, which led them to believe that the EGPWS had malfunctioned. Thus, the EGPWS was de-activated by pulling the circuit breaker. The management had identified that some pilots including the accident pilot were pulling the EGPWS's circuit breaker.(p45)
As per the final report, the investigation concluded that the EGPWS power supply circuit breaker was pulled during the accident flight and the two previous flights, explaining the absence of the altitude call out during the two previous approaches and warning prior to the impact. Further investigation revealed that Trigana Air's published approach chart which it provided the pilot had incorrect information. The approach chart stated that the minimum safe altitude was at 8,000 ft. Flight 267 impacted the mountain at 8,300 ft. The NTSC concluded that the approach chart was wrong, ineffective and hard to understand. Aircraft maintenance was also badly performed by the airline.
The final report concluded that the accident resulted from a controlled flight into terrain caused by the crew's decision to deviate from its projected flight path. The absence of EGPWS warnings aggravated the condition
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