Continuing on from “Let’s be fair shall we?” blog article , I had complained about all the talk in the media and politics being irrelevant to the accident (they can rattle their sabers all they like). In that blog article I mentioned that the visibility was 2 kilometers and that the visual approach into Kaimana in that condition would be illegal.

Some have asked me in private where I got the information from (most of the media articles only mentioned “bad weather”) and few have even said, “how dare you accuse?”

Today I come across two links related to the accident that occured on 7th May:

  1. Aviation Safety News – interim safety recommendations from the National Transportation Safety Comission
  2. Preliminary accident investigation report from the NTSC (in Indonesian)

The report mentioned:

  • Kaimana has no instrument approach procedures, therefore the approach has to be performed under Visual Flight Rules.
  • Weather information (at 0300Z) for Kaimana prior to departure was 8km visibility, 4/8 cloud cover at 1400ft cloud base, wind from the south east at 6 knots and surface temperature was 29C. The flight was legal to start.
  • Passing JOLAM At 0425Z, aircraft provided an ETA of 0454Z to Kaimana AFIS. Kaimana AFIS reported the weather conditions as: 3-8km, few cumulonimbus with cloud base f 1500ft, wind from south west at 3knotd and surface temperature of 29C.
  • At 0430Z aircraft descended from 15500ft, and was requested to report again 5 minutes out.
  • At 0442Z, aircraft reported 7NM out passing 8000ft. Crew asked if it was still raining and was replied that it was, and they decided to proceed to the south of the airfield.
  • At 0445UTC, aircraft reported to be 15NM south of the airfield at 5000ft and waiting for a change in weather. Airport was still raining with 2km vsibility.
  • The last contact with the aircraft was around 0450Z where the crew asked if the visibility has changed. AFIS replied that the visibility was still 2km and that the threshold of runway 01 can be seen from the tower.
  • The aircraft impacted at roughly 800m south east from runway 01, 500m from the coastline. Most of the wreckage sunk in shallow waters of 7 to 15 meters deep.
  • AFIS received reports from eyewitness as the impact location was obscured from the tower by trees.
  • Aircraft was destroyed, 25 people had died.
  • FDR was retreived on 9th May and the CVR retrieved the next day.

Safety Actions:

  • DGCA has conducted an audit of Merpati since 10th May.
  • Merpati has issued a safety recommendation on 11th May:
    • Aircrew are reminded to abandon the approach/landing if the conditions dictate.
    • Pay attention to the visual flight rules and instrument approach minimum
    • Observe the 9 criterias of a stabilized approach.
    • Reinforce the mandatory training and simulator sessions including windshear, CRM, approach landing accident reduction and go-around indoctrination.
    • Dispatchers to provide the latest weather information and anticipate flights to Return To Base.
    • Ensure technical inspections on pre-flight, transits and daily checks as per the checklists and immediately report each finding to the Maintenance Control Center.

The NTSC has issued the following recommendations:

  • To Merpati Nusantara Airlines:
    • Ensure that visual flight is being conducted in accordance with VFR conditions, and conduct training on the MA60 Crew Simulator with an emphasis on CRM in the face of the bad weather.
  • To the Director General of Civil Aviation:
    • Monitor the implementation of the recommendations in point A , to be carried out  by Merpati Nusantara Airlines.
  • To Directorate General of Civil Aviation and Directorate of Airports:
    • Review the provisions of the use of facilities / equipment, especially the airport runway lights to enhance the safety of flight operations, especially in low visibility conditions.

So, whilst the facts has been established, the question remains, WHY DID THEY ATTEMPT AN APPROACH BELOW MINIMA? (in the meantime, politicians and born-yesterday heroes can continue to rant senselessly!)

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