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Report: Indonesian Xian MA60 struck sea during missed approach in below-minima conditions
7 May 2012

Final segment of the flight (source: NTSC)

The Indonesian National Transportation Safety Committee (NTSC) concluded that an unprepared crew lost situational awareness during an approach to an airport in below-minima weather conditions. Their Xian MA60 passenger plane struck the sea during a missed approach.

On May 7, 2011, Merpati Nusantara Airlines flight MZ8968 departed Sorong (SOQ) on a flight to Kaimana (KNG), Indonesia. There were 19 passengers and six crew members on board the MA60 turboprop plane. It was raining an Kaimana with a reported visibility of 2000 m. This was below minima, but the crew decided to conduct an approach.

During the approach to Kaimana, the flight crew flew to the south of the airport in an attempt to make a visual approach over water. The auto-pilot was disengaged at 960 feet pressure altitude. At 376 feet pressure altitude, the crew decided to discontinue the approach and climbed, turning to the left. Engine power was increased and flaps were retracted from 15 to 5 and subsequently to 0 degrees. The landing gear was also retracted. The aircraft rolled to the left with a bank angle of 11° and continuously increased up to 38°. The rate of descend increased significantly up to about 3000 feet per minute and the airplane finally impacted into the shallow sea.

The investigation concluded:

1. The flight was conducted in VFR in condition that was not suitable for visual approach when the visibility was 2 km. In such a situation a visual approach should not have been attempted.
2. There was no checklist reading and crew briefing.
3. The flight crew had lack of situation awareness when tried to find the runway, and discontinued the approach.
4. The missed approach was initiated at altitude 376 feet pressure altitude (250 feet radio altitude), the pilot open power to 70% and 82% torque followed by flap retracted to 5 and subsequently to 0. The rapid descent was mainly caused by continuously increase of roll angle up to 38 degree to the left and the retraction of flaps from 15 to 0 position.
5. Both crew had low experience/flying time on type.
6. Inadequacy/ineffectivity in the training program may lead to actions that deviated from the standard procedure and regression to the previous type.

 

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