KNKT.15.02.04.04 - PT. Garuda Indonesia ATR 72‐600; PK‐GAG Lombok International Airport Republic of Indonesia 03 February 2015 PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 1 The handling of the aircraft was contrary to the wind condition. The KNKT recommends that the operator shall emphasized the crosswind handling. OPEN 27-Jan 2020 9-Mar-2017 Chief Pilot ATR has issued notice no. 03/15 and 04/15 date 11 February 2015 to all ATR Flight Crew regarding “Safety Precaution regarding event GA7040 at LOP” which contained key points for a safe and successful crosswind landing. ATURAN KNKT.15.02.04.04 - PT. Garuda Indonesia ATR 72‐600; PK‐GAG Lombok International Airport Republic of Indonesia 03 February 2015 PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 2 In the preliminary report of this investigation, KNKT issued recommendation related to standard call out on final. In addition, investigation identified two change over control of the flight at critical phase of flight without clear statements. This condition may also extend to the other instructors within the company. Therefore, KNKT recommends to review the policy of change over control at critical altitude. OPEN 27-Jan 2020 9-Mar-2017 VP Flight Operations has issued notice no. 04/15 date on 9 February 2015 to all Flight Crew. Chief Pilot ATR has issued notice no. 04/15 date 11 February 2015 to all ATR Flight Crew regarding “Safety Alertness Regarding Critical Phase of Flight” which instructed all PiC to keep maintain situational awareness in all phase of flight (Approach and Landing) with follow procedures consistently at 500’ Agl PiC as Pilot PENGAWASAN REKOMENDASI (RECOMMENDATION) STATUS 1 TANGGAL KEJADIAN (DATE OF OCCURRENCE) SUMBER (SOURCE) TANGGAL DIKELUARKAN (DATE OF ISSUED) INSTANSI PENERIMA (ADDRESS TO) KATEGORI (CLASSIFICATION) TANGGAPAN (RESPONSE) STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES) TAHUN 2007 - 2020 (Data s.d Januari 2021) NO INVESTIGASI (INVESTIGATION) REGISTRASI PESAWAT (AIRCRAFT REGISTRATION) TANGGAL DITERIMA (RESPONSE DATE) NOMOR REKOMENDASI (RECOMMENDATION NUMBER) BATAS WAKTU (DUE DATE)
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KNKT.15.02.04.04 - PT.
Garuda Indonesia
ATR 72‐600; PK‐GAG
Lombok International
Airport
Republic of Indonesia
03 February 2015
PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 1The handling of the aircraft was contrary to the wind condition. The KNKT
recommends that the operator shall emphasized the crosswind handling. OPEN 27-Jan 2020 9-Mar-2017
Chief Pilot ATR has issued notice no. 03/15 and 04/15
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
KNKT.15.10.21.04 - PT.
Aviastar Mandiri
DHC-6 Twin Otter; PK-
BRM
at coordinate 3° 25'
52.80" S, 120° 4' 12.10"
E
District of Luwu, South
Sulawesi
Republic of Indonesia
2 October 2015
PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 34 1 To consider instrument flight training for search and rescue pilots. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN
KNKT.15.10.21.04 - PT.
Aviastar Mandiri
DHC-6 Twin Otter; PK-
BRM
at coordinate 3° 25'
52.80" S, 120° 4' 12.10"
E
District of Luwu, South
Sulawesi
PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 35 1 To consider using drone or unmanned aerial vehicle for air search operation. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
REKOMENDASI (RECOMMENDATION) STATUS
TANGGAL KEJADIAN
(DATE OF
OCCURRENCE)
SUMBER (SOURCE)
TANGGAL
DIKELUARKAN (DATE OF
ISSUED)
INSTANSI PENERIMA
(ADDRESS TO)
KATEGORI
(CLASSIFICATION)TANGGAPAN (RESPONSE)
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
KNKT.17.08.25.04 -
PT. Lion Airlines dan
PT. Wings Abadi Airlines
Boeing 737-900ER; PK-
LJZ dan ATR 72-500;PK-
WFF
Kulanamu International
Airport, Medan -
Republic of Indonesia
3 August 2017
PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 6The KNKT recommends to ensure air traffic controllers consider the possible
hazard when using RET for departure aircraft. CLOSED 7-Feb 2020
The AirNav Indonesia amended the ATS SOP for
Aerodrome Control Tower to include detail procedure
to use of Rapid Exit Taxiway (RET) as follows:
If controller will use RET for departure traffic, the
controller must consider:
- The use of RET will expedite and avoid delay, or to
optimize the use of runway;
- The remaining runway is sufficient for aircraft to
takeoff;
- No aircraft conducts landing approach on long
final/final/inbound heading; and
- No objection from pilot to use RET for takeoff.
The procedure for using RET for departure is as follows:
- Controller must advise the remain runway length to
the pilot;
- The use RET on opposite runway condition is
prohibited; and
- The use of conditional phrase/clearance is prohibited.
PENGAWASAN
KNKT.17.08.25.04 -
PT. Lion Airlines dan
PT. Wings Abadi Airlines
Boeing 737-900ER; PK-
LJZ dan ATR 72-500;PK-
WFF
Kulanamu International
Airport, Medan -
Republic of Indonesia
3 August 2017
PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 7The KNKT recommends to review the ATS SOP to include detail procedure or
guideline for air traffic controller.OPEN 7-Feb 2020
The AirNav Indonesia amended the ATS SOP for
Aerodrome Control Tower including the prohibition to
use the use of conditional phrase/clearance is
prohibited.
ATURAN
KNKT.17.04.10.04 - PT.
Spirit Avia Sentosa
(FlyingSAS); Cessna
2018; PK-FSO; Anem
Mountain, Oksibil
Papua
PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan
Penerbangan04 L 2017 10 3
The KNKT recommend the Aviation Medical Center to conduct the required
examination including ECG resting or ECG exercise in accordance with the
CASR part 67.
CLOSED 29-Jan 2020 24-Aug-2019
The Aviation Medical Center had developed an
integrated online medical record application which
included the exercises need to be completed based on
CASR part 67 as a default step to be completed in the
application. Special issuance for pilots who could not
performed or does not meet the requirement and
standard for ECG resting or exercise, shall be discussed
in Medical Review Board for further evaluation
ATURAN
KNKT.17.04.10.04 - PT.
Spirit Avia Sentosa
(FlyingSAS); Cessna
2018; PK-FSO; Anem
Mountain, Oksibil
Papua
PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan
Penerbangan04 L 2018 10 4
The KNKT recommend the Aviation Medical Center to conduct examiner
workload analysis to adjust the ration of examiner and applicant so that the
examination can be performed thoroughly.
CLOSED 29-Jan 2020 24-Aug-2019
The Aviation Medical Center (AMC) had reviewed the
ratio between examiner and their workload, and
conducted workload analysis. The result of the analysis
was the AMC need 11 examiners. After the accident,
the AMC had added 5 examiners and currently had 15
STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)
TAHUN 2007 - 2020 (Data s.d Januari 2021)
NOINVESTIGASI
(INVESTIGATION)
REGISTRASI PESAWAT
(AIRCRAFT
REGISTRATION)
TANGGAL DITERIMA
(RESPONSE DATE)
NOMOR REKOMENDASI
(RECOMMENDATION NUMBER)
BATAS
WAKTU (DUE
DATE)
KNKT.17.11.33.04 - PT.
Wings Abadi Airlines &
BP3 Banyuwangi - ATR
72-212A & CESSNA 172S
Near point NAMP
ISLAND, NTB
21 November 2017
PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 1The KNKT recommend to AirNav Indonesia to ensure air traffic controller
provides all necessary information to the accepting unit as stated in the SOP.CLOSED 7-Feb 2020
The AirNav Indonesia developed Rating Examination
Guidelines for Air Traffic Controller which included:
- 8 hours classroom briefing session to rehears
technical knowledge of air traffic control, including the
procedure of coordination with the adjacent units;
- theoretical check based on the classroom session
material;
- practical check during daily duty which included the
coordination procedures of information transfer and
update methods.
PENGAWASAN
KNKT.17.11.33.04 - PT.
Wings Abadi Airlines &
BP3 Banyuwangi - ATR
72-212A & CESSNA 172S
Near point NAMP
ISLAND, NTB
21 November 2017
PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 2The KNKT recommend to AirNav Indonesia to ensure air traffic controller
maintain listening watch to all communication.CLOSED 7-Feb 2020
The AirNav Indonesia developed Rating Examination
Guidelines for Air Traffic Controller which included:
- 8 hours classroom briefing session to rehears
technical knowledge of air traffic control, including the
requirement to maintain the listening watch;
- theoretical check based on the classroom session
material;
- practical check during daily duty which included the
requirement to maintain the listening watch.
The AirNav Indonesia conducted technical briefing for
all personnel before their duty which included the
PENGAWASAN
KNKT.18.01.01.04; PT.
Batik Air Indonesia dan
PT. Lion Mentari
Airlines; Airbus A320-
200 dan Boeing 737-
900ER; Near Waypoint
Tirus Surabaya, East of
Java
PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018 Batik Air 04 O 2018 1 1
The duty and flight hour of both pilot did not exceed the requirement of the
OM – Part A however, the slip of altitude clearance between the pilot mind
and the readback, the ability to monitor the other traffic communication and
feeling sleepy were indications of pilot fatigue. The fatigue might be caused by
overnight flight which increasing of potential fatigue was not fully recovered,
and the condition of the pilots woke up in early morning might reduce the
time for recovery sleep
Therefore, KNKT recommends the Batik Air to establish fatigue risk
management which may refer to ICAO Annex 6 and ICAO Document 9966.