Sabang Merauke Raya C212 near Batam on Feb 12th 2011, lost height enroute, both engines inoperative
Last Update: November 21, 2012 / 15:16:15 GMT/Zulu time
Incident Facts
Date of incident
Feb 12, 2011
Classification
Crash
Aircraft Type
CASA Tp89 Aviocar
ICAO Type Designator
C212
- The flight test was not properly well prepared; there was no flight test plan.
- The current and applicable CMM is dissimilar the According to the CASA 212-100 and Garrett TPE331-5 Maintenance Manuals related to flight test requirement after the change of only one engine.
- The left engine was shut down using normal/ ground shut down procedure. It used the fuel shut off switches off followed by pulling the Power Lever rearward to reverse, as indicated by the propeller pitch.
- The right engine most likely shut down by wind milling prior the impact, it was indicated the propellers piston distance position to the cylinder was about normal flight range position and no indication of rotating impact on the blades.
- The Casa Service Bulletin No. 212-76-07 Revision 1 issued dated 23 December 1991 (Anti Reverse) that applicable for Casa 212 -100/200, was not incorporated to this aircraft.
- The PIC with pareses or paralysis vestibular organ or system could not response normally to the three dimensional motion or movement. This condition may the subject more sensitive to suffer Spatial Disorientation (SDO). The SDO is the pilot could not perceived rightly his position motion and attitude to the earth horizontal or to his aircraft or other aircraft and could as the dangerous precondition for unsafe action.
- The Director (DGCA) decree No 30/II/2009 issued on 20 February 2009 stated that for issuing medical certificate for pilot after 60th birthday require several additional medical examination items. Point 1.b of this decree states the Video Nystagmography examination.(differed the ICAO Doc 8984).
The aircraft had undergone a #1 (left hand) engine change and was to perform a test flight which after departure from Batam would lead the aircraft into the area of Tanjung Pinang. Besides the two flight crew there were three company engineers on board of the aircraft.
The aircraft had not received the modifications according to Casa Service Bulletin No. 212-76-07 released 1991 that would have prevented the unintentional or intentional setting of power levers into reverse while in flight.
The captain (61, ATPL, 13,027 hours total, 3,311 hours on type), pilot flying and pilot monitoring not identified by the report, was found without training or qualification to conduct a test flight, he had originally not been assigned to the flight. Medical checks showed that he suffered "severe pareses or paralysis (peripheral vestibular lesion) on the right vestibular organ." The vestibular organ regulates balance and sensing of the position and attitude of the body, the medical check on Jan 19th 2011 showed the "caloric response was 116% weakness on the right ear", which could result in the person feeling dizzy, it is possible that balance is being disturbed by three dimensional movements like rolling, yawing and pitching during flying. ICAO regulations require the difference between left and right vestibular organ being less than 20%.
The first officer (50, CPL, 2,577 hours total, 152 hours on type) was found without anomalies.
The aircraft had accumulated 29,990 hours in 35,128 cycles, the left hand engine TPE-331-5-251C had accumulated 19,942 hours since new and 0 hours since last overhaul, the right hand engine had accumulated 7,193 hours since new and 2,675 since last overhaul (overhaul intervals 6000 hours). The left hand propeller had accumulated 568 hours since new and 49 hours since overhaul, the right hand propeller 5,373 hours since new and 898 hours since last overhaul (overhaul intervals 3000 hours).
The aircraft carried an additional recently overhauled engine in the mid cabin.
The aircraft departed Batam at 06:18Z (13:18L) and appeared on Tanjung Pinang Approach radar at 06:28Z at 2000 feet. At 06:33Z the aircraft was cleared to climb to 4000 feet. At 06:44Z radar contact with the aircraft was lost 16nm from Tanjung Pinang on radial 016 Tanjung Pinang, radio calls went without reply. Other aircraft were not able to communicate with PK-ZAI, too, at 07:06Z the Indonesian Air Force Base at Gunung Bintan reported an aircraft had crashed at Gunung Kijang Forest.
A subsequent search located the aircraft at final position N1.1792 E104.5728, all occupants had perished, the aircraft was destroyed. The first impact mark was found 16 meters to the west of the main wreckage, where the aircraft had impacted and broken a tree at 6 meters of height.
Examination of the left propeller showed, that the left propeller blades showed no indication of rotation prior to impact. The propeller blades were on fine pitch or reverse position.
The right hand propeller also showed no indication of rotation prior to impact, the mechanics was in a position of about normal flight range.
Tear down inspections of both engines revealed they were damaged as result of external impact forces.
The cockpit voice recorder did not record any communication beyond communication with ATC, there was no internal crew communication with each other or with the engineers on the 30 minutes of recordings downloaded by the NTSC facility. The aircraft carried no flight data recorder nor was it required to carry a FDR.
The investigation did not find the required inspection item release on the engine removal and installation task card. The inspection also found no company maintenance program related to the CASA-212 aircraft.
The investigation analysed that the left hand engine most likely was in beta (reverse), which could be the result of executing the ground shut down procedure, which would use the fuel shut off switches followed by the propellers pulled rearward to reverse position. It was likely the propeller and engine were windmilling for some time due to the blades in fine pitch position.
The investigation analysed that the right hand engine mechanics indicated about normal operating range. It is likely that the propeller was moving out of cruising pitch angle due to wind milling prior to impact.
The left hand engine most likely shut down some time ahead of the right hand engine.
The report makes no mention of in what positions the various levers of the throttle quadrant were found or the state of the cockpit in general. The report also does not attempt to determine scenarios that could have led to the shut down of either engine and especially the second shut down with one engine already shut down.
Incident Facts
Date of incident
Feb 12, 2011
Classification
Crash
Aircraft Type
CASA Tp89 Aviocar
ICAO Type Designator
C212
This article is published under license from Avherald.com. © of text by Avherald.com.
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