Incident Overview

Date: Sunday 16 August 2015
Aircraft Type: ATR 42-300
Owner/operator: Trigana Air Service
Registration Number: PK-YRN
Location: 16,7 km NW of Oksibil Airport (OKL) – ÿ Indonesia
Phase of Flight: En route
Status: Destroyed, written off
Casualties: Fatalities: 54 / Occupants: 54
Component Affected: EGPWS Warning System, Pilot Behavior, Aircraft Navigation Systems (specifically EGPWS circuit breaker).EGPWS Warning System, Pilot Behavior, Aircraft Navigation Systems (specifically EGPWS circuit breaker).
Investigating Agency: NTSCNTSC
Category: Accident
A fatal aviation incident occurred on Trigana Air Service flight 267 near Oksibil Airport in Papua, Indonesia, resulting in the deaths of all four crew members. The aircraft impacted a mountainside, and the flight was expected to arrive at Oksibil Airport at 15:04 UTC. The pilot initiated a direct left base leg for runway 11, but the Oksibil Aerodrome Flight Information Services (AFIS) controller instructed the pilot to continue approach and call when position on final for runway 11. The pilot subsequently deviated from standard approach procedures, including failing to activate the EGPWS warning, which contributed to the accident. Investigation revealed a potential issue with pilot behavior, specifically the circuit breaker being pulled to eliminate EGPWS warnings, leading to a lack of awareness of the hazardous situation. The aircraft wreckage was discovered approximately 17 km from the airport on a ridge.A fatal aviation incident occurred on Trigana Air Service flight 267 near Oksibil Airport in Papua, Indonesia, resulting in the deaths of all four crew members. The aircraft impacted a mountainside, and the flight was expected to arrive at Oksibil Airport at 15:04 UTC. The pilot initiated a direct left base leg for runway 11, but the Oksibil Aerodrome Flight Information Services (AFIS) controller instructed the pilot to continue approach and call when position on final for runway 11. The pilot subsequently deviated from standard approach procedures, including failing to activate the EGPWS warning, which contributed to the accident. Investigation revealed a potential issue with pilot behavior, specifically the circuit breaker being pulled to eliminate EGPWS warnings, leading to a lack of awareness of the hazardous situation. The aircraft wreckage was discovered approximately 17 km from the airport on a ridge.

Description

Trigana Air Service flight 267, an ATR 42-300, was destroyed when it impacted a mountainside near Oksibil Airport in Papua, Indonesia. All 49 passengers and five crew members sustained fatal injuries. The ATR-42 departed Jayapura at 14:22 LT (05:22 UTC) and was expected to arrive at Oksibil at 15:04 LT (06:04 UTC). At 14:55 the pilot made first contact with Oksibil Aerodrome Flight Information Services (AFIS), reporting cruising at 11500 feet over position Ambisibil. The AFIS controller acknowledged the message and instructed the pilot to report when overhead the airport. The pilot reported that they intended to fly a direct left base leg for runway 11. The Oksibil AFIS officer then told the pilot to continue approach and to call when position on final for runway 11. There was no further contact with the flight. The aircraft wreckage was found the next day on a ridge of Tanggo Mountain at approximately 8,300 feet AMSL, about 17 km from the airport. The investigators concluded that the flight crew deviated from the standard approach procedure over mountainous terrain. There was no EGPWS warning nor any other EGPWS callout during the descent. The Oksibil Airport was not provided with the high-resolution terrain data in the database version installed on the accident aircraft’s EGPWS. Additionaly, some pilots within the air operator had experiences that the EGPWS warning became active in a condition that according to the pilots, the warning is not appropriate. These experiences led to the pilot behaviour of pulling the EGPWS circuit breaker to eliminate nuisance of EGPWS warning that considered unnecessary. The investigators could not determine the actual EGPWS CB position during the accident flight. Contributing Factors: 1. The deviation from the visual approach guidance in visual flight rules without considering the weather and terrain condition, with no or limited visual reference to the terrain resulted in the aircraft flew to terrain. 2. The absence of EGPWS warning to alert the crew of the immediate hazardous situation led to the crew did not aware of the situation.

Primary Cause

Deviation from standard approach procedures and failure to activate the EGPWS warning system, leading to a lack of situational awareness and potential for a hazardous situation.Deviation from standard approach procedures and failure to activate the EGPWS warning system, leading to a lack of situational awareness and potential for a hazardous situation.

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