CASA/Nurtanio NC-212-A4 Aviocar 100 – PK-ZAI

Incident Overview

Date: Saturday 12 February 2011

Aircraft Type: CASA/Nurtanio NC-212-A4 Aviocar 100

Owner/operator: Sabang Merauke Raya Air Charter

Registration Number: PK-ZAI

Location: ca 15 km N of Tanjung Pinang-Kidjang Airport (TNJ), Bintan Island – ÿ Indonesia

Phase of Flight: En route

Status: Destroyed, written off

Casualties: Fatalities: 5 / Occupants: 5

Component Affected: The left engine was shut down using standard ground/engine shutdown procedures, but the propeller pitch was reversed, potentially contributing to the crash.The left engine was shut down using standard ground/engine shutdown procedures, but the propeller pitch was reversed, potentially contributing to the crash.

Investigating Agency: NTSCNTSC

Category: Accident

A CASA/Nurtanio NC-212-A4 Aviocar 100 aircraft crashed at Bintan Island, Indonesia, resulting in the deaths of all five occupants. The aircraft was damaged beyond repair due to a catastrophic engine failure. The incident occurred during a test flight over Bintan Island, following an engine replacement to the first engine. The flight ascended to 4000 feet, heading for Tanjung Pinang-Kidjang Airport (TNJ), and crashed nose-down in a jungle area at approximately 15 NM from the VOR. Factors contributing to the accident included a poorly prepared test flight, a discrepancy between the CASA 212-100 and Garrett TPE331-5 maintenance manuals regarding flight test requirements, a faulty left engine shutdown procedure, and a lack of integration of the Anti-Reverse Service Bulletin (ARSB) from 1991. The pilot experienced vestibular issues, potentially leading to Spatial Disorientation (SDO), which could have impaired their situational awareness and contributed to the crash.A CASA/Nurtanio NC-212-A4 Aviocar 100 aircraft crashed at Bintan Island, Indonesia, resulting in the deaths of all five occupants. The aircraft was damaged beyond repair due to a catastrophic engine failure. The incident occurred during a test flight over Bintan Island, following an engine replacement to the first engine. The flight ascended to 4000 feet, heading for Tanjung Pinang-Kidjang Airport (TNJ), and crashed nose-down in a jungle area at approximately 15 NM from the VOR. Factors contributing to the accident included a poorly prepared test flight, a discrepancy between the CASA 212-100 and Garrett TPE331-5 maintenance manuals regarding flight test requirements, a faulty left engine shutdown procedure, and a lack of integration of the Anti-Reverse Service Bulletin (ARSB) from 1991. The pilot experienced vestibular issues, potentially leading to Spatial Disorientation (SDO), which could have impaired their situational awareness and contributed to the crash.

Description

A CASA/Nurtanio NC-212-A4 Aviocar 100 plane, registered PK-ZAI, was damaged beyond repair in an accident at Bintan Island, Indonesia. All five on board were killed. The airplane departed from Batam-Hang Nadim Airport (BTH) at 13:18 for a test flight following an engine replacement to the engine number one. The test flight was conducted over Bintan (Tanjung Pinang) Island area. There were five persons on board consisted of two pilots, and three company engineers. The flight climbed to the en route cruising altitude of 4000 feet, heading for Tanjung Pinang-Kidjang Airport (TNJ). The airplane crashed nose down in the jungle at the 010 radial of the TPG VOR at a distance of about 15 NM from the VOR. Factors contributed to the accident are as follows: – 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)

Primary Cause

Inadequate preparation for a test flight, specifically a lack of a proper flight test plan and a discrepancy in maintenance manuals, led to a catastrophic engine failure.Inadequate preparation for a test flight, specifically a lack of a proper flight test plan and a discrepancy in maintenance manuals, led to a catastrophic engine failure.

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