Jakarta collision on runway, Preliminary Report

Released May, 11th, 2016.

A Batik Air Boeing 737-800, registration PK-LBS performing flight ID-7703 from Jakarta Halim Perdanakusuma to Ujung Padang (Indonesia) with 49 passengers and 7 crew, was on the takeoff roll on runway 24 at 19:55L (12:55Z) when its left wingtip entangled with the vertical tail and left wing of a Transnusa Avions de Transport Regional ATR-42-600 registration PK-TNJ crossing the runway under tow and separated the most of the vertical tailplane as well as the left wing from the ATR, the left wing tank ruptured open. Both aircraft caught fire, the Boeing was evacuated via slides. Fire engines responded and were able to put the fires out in a matter of minutes. There were no injuries, both aircraft received substantial damage.(This paragraph excerpted from The Aviation Herald http://avherald.com/h?article=49666e3e&opt=0)

Batik 738 (2)

Photo: http://static.republika.co.id/uploads/images/inpicture_slide/160405174200-152.jpg

FACTUAL INFORMATION

History of the Flight

On 4 April 2016, Boeing 737-800 registered PK-LBS (1 Boeing 737-800 aircraft registered PK-LBS will be named as ID 7703 ) was being operated by Batik Air as scheduled passenger flight with flight number ID 77031 from Halim Perdanakusuma International Airport (2 Halim Perdanakusuma Airport will be named as Halim for the purpose of this report) with intended destination Sultan Hasanuddin International Airport Makassar. On board, this flight, was 56 persons consist of two pilots, five flight attendants, and 49 passengers.

Batik 738

Figure 1: Archive photo of PK-LBS (courtesy of jetphotos.net)

An ATR 42-600 aircraft, registration PK-TNJ 3( 3.ATR 42-600 aircraft registered PK-TNJ will be named as towed aircraft) operated by TransNusa Aviation Mandiri was parked at parking stand B-1 on the north apron of Halim. The TransNusa Aviation Mandiri engineer was instructed by the Apron Movement Control (AMC) to move PK-TNJ aircraft from north to south apron.

PK-TNJ aircraft was moved used a towing car. On board, the towing car, was one driver and one supporting personnel, while on board in the cockpit of the towed aircraft were two engineers. The engineers were assigned to apply aircraft brake if required during the towing process.

The towed aircraft was towed without aircraft electrical power fed to the system and neither of navigation light, strobe light, and the aircraft radio communication was ON.

An engineer of TransNusa Aviation Mandiri stated that the aircraft battery could be used to activate the aircraft radio communication but could not be used to activate the aircraft navigation lights. Therefore, during the towing process, the aircraft navigation light were not activated. The communication between the towing car driver and Halim Tower was performed by a handheld radio communication on frequency 152.7 MHz.

Trans Nusa ATR

Figure 2: Archive photo of PK-TNJ (courtesy of jetphotos.net)

The air traffic controller set crew on duty consisted of controller, assistant controller, supervisor and flight data officer. The lights in the tower cab (4 Tower cab is a working room for the air traffic controller on the top of the tower building) were illuminated and there were several lights reflection on the tower glass windows including the view to the direction of the beginning runway 24.

At 1245 UTC 5 The 24-hour clock used in this report to describe the time of day as specific events occurred is in Coordinated Universal Time (UTC) Local time that will be used in this report is Waktu Indonesia Barat (WIB) or Indonesia Western Time which is UTC + 7 hours), the ID 7703 pilot requested pushback clearance to the Halim Tower controller (controller) on Halim Tower radio frequency of 118.6 MHz. The aircraft was parked on the parking stand B-2 and was approved to push back.

After the ID 7703 completed the pushback, the towing car driver of the towed aircraft requested clearance to Halim Tower Control Unit (Halim Tower) to reposition from parking stand B-1 to the south apron. The towing car driver was instructed to follow ID 7703 and to report when on taxiway “C”. The communication between the towing car driver and Halim Tower was performed by a handheld radio communication. This communication was handled by the assistant controller (assistant).

The controller heard the communication between the assistant and towing car driver, he recognized the position of the towed aircraft was on the parking stand B-1. The controller did not see the towed aircraft exterior lights illuminated during the movement.

The ID 7703 pilots did not know that there was a towing aircraft behind.

At 1248 UTC, the ID 7703 pilot received taxi clearance to runway 24 via taxiway “C”.

At 1250 UTC, the controller instructed the ID 7703 pilot to hold on taxiway “C” due to arriving aircraft.

The assistant stated that when the ID 7703 was holding on short taxiway “C”, the towed aircraft started to tow.

At 1253 UTC, the ID 7703 pilot received clearance from the controller to enter backtrack runway 24.

There was an arriving aircraft that would use the parking stand B-1 therefore, the assistant instructed the towing car driver to expedite the tow and report when on taxiway “C”. The towed aircraft position was on abeam (Abeam is at a right angle to the fore and aft line of a vessel or an aircraft) parking stand B-9.

The assistant noticed the last position of the towed aircraft was when the aircraft abeam the tower building, thereafter the assistant conducted coordination with the other ATS unit related to other departure aircraft. The assistant did not recall any visible light of towed aircraft except the light from the towing car.

The towing car driver explained that when about entering taxiway “C”, the assistant instructed to expedite the towing and follow ID 7703 and was acknowledged by the towing car driver.

The towing car driver stated that when the towed aircraft on taxiway “C”, the assistant instructed to expedite the towing, and was acknowledged by towing car driver. Thereafter, the towing car driver clarified that the taxi route was via taxiway “G” and was affirmed by the assistant. Meanwhile, the ID 7703 was still on backtrack runway 24.

At 1256 UTC, the ID 7703 pilot reported ready for takeoff. The controller did not see any vehicle or object on the runway then issued clearance for takeoff to the ID 7703 pilot. 11

The pilot stated that during line up, the lights surrounding the turning pad were very bright and affected his forward vision for a short time. It was common practice in Halim to line up at the turning pad beyond the threshold runway 24.

After received the takeoff clearance, the Second in Command (SIC) as pilot flying (PF) opened the power and pressed the Take Off / Go Around (TOGA) button.

The towing car driver stated that when he saw the ID 7703 was lining up for takeoff then asked the Halim Tower whether the ID 7703 was initiating the takeoff, and there was no reply from the Halim Tower. The towing car driver then speeds up the towing and turned to the right side of the runway.

When ID 7703 was on rolling takeoff at approximate 80 knots, the SIC saw an object and confirming to the Pilot in Command (PIC) concerning to the object. The pilots could not identify the object but later on, when the object became closer, the SIC realized that there was an aircraft.

The PIC took over control and applied the right rudder towards the right side of the runway centerline and maintained between the runway centerline and the runway edge. The PIC intended to reject the takeoff shortly after the pilot felt an impact. The pilot performed the rejected takeoff and the ID 7703 stopped at approximately 400 meters from the towed aircraft which stopped at the left of the runway 24 centerline at approximately 100 meters from taxiway “G”.

The assistant saw fire on the left side of ID 7703 when the aircraft rolled between taxiway “C” and “B”. Then the assistant pressed the crash bell and informed Rescue and Fire Fighting Service (RFFS) about the fire.

After the aircraft stopped, the PIC commanded to the SIC to perform “ON GROUND EMERGENCY” procedure and commanded to the flight attendant “ATTENTION CREW ON STATION” twice. The PIC noticed fire on the left wing tip and immediately shut down both engines, activated the fire extinguishers of both engines and Auxiliary Power Unit (APU) and commanded to the flight attendant “evacuation from the right”.

After the aircraft stopped and received the PIC command “ATTENTION CREW ON STATION”, the flight attendants checked the condition inside and outside the aircraft through the viewing window. There was no damage inside the aircraft and they did not see any fire outside the aircraft.

The flight attendants opened all aircraft passenger doors and the escape slides deployed. Most of the passengers were evacuated from the left forward door (1L).

The pilots realized that the impacted object was a towing aircraft after they disembarked the aircraft.

The air traffic controller set crew realized that the towed aircraft was on the runway and collided with ID 7703 after asked to the towing car driver.

No one injured in this occurrence.

Damage to Aircraft

ID 7703

The damaged to aircraft were as follows:

– The left wing damaged approximately 575 centimeters from the wingtip.

– The wingtip damaged in two parts.

ATR-B738 colision

Figure 3: The damaged left wing

1.3.2 Towed Aircraft

The damaged to aircraft were as follows:

– The left wing damaged approximately 260 centimeters from the wingtip.

– The vertical stabilizer damaged including the horizontal stabilizer.

ATR-B738 colision (2)

Figure 4: The detached part of wing and horizontal stabilizer

OtherDamage

There was no environment and other damage reported.

Communications

All communications between air traffic controller and the ID 7703 pilot on frequency 118.6 MHz were recorded by ground-based automatic voice recording equipment and the ID 7703 Cockpit Voice Recorder (CVR). The quality of the recorded transmissions was good.

The communication between Halim Control Tower Unit and towed car driver on frequency 152.7 MHz was not recorded.

The following is the excerpt of the communication between towing car driver and Halim Tower unit on frequency 152.7 MHz was based on interview statement with the related person on duty during the towing process.

At parking stand B-1:

The towing car driver requested reposition from parking stand B-1 to the south apron to Halim Control Tower Unit (Halim Tower) and replied by the flight data officer to standby. After the ID 7703 moved forward, the towing car driver instructed by Halim Tower unit to continue towing and report taxiway “C”. 19

Abeam parking stand B-9:

Assistant controller instructed towing car driver to expedite the towing following ID 7703 and acknowledged by towing aircraft driver.

At about entering taxiway “C”:

Assistant controller instructed towing car driver to expedite the towing following ID 7703 and acknowledged by towing aircraft driver.

At taxiway “C”:

Assistant controller instructed towing car driver to expedite the towing, and acknowledged by towing aircraft driver. The towing car driver confirmed the taxi route via taxiway “G” and affirmed by the assistant controller.

On the runway between taxiway “G” and “H”:

The towing car driver asked Halim Tower whether the ID 7703 take off twice and there was no reply.

Aerodrome Information

Airport Name: Halim Perdanakusuma International Airport
Airport Identification: WIHH / HLP
Airport Operator: PT. Angkasa Pura II (Persero)
Airport Certificate: 008/SBU-DBU/VII/2010
Coordinate: 06°17’03”S 106°53’06”E
Elevation: 84 feet
Runway Direction: 06 – 24
Runway Slope: 0.07% down to east
Runway Length: 3,000 meters
Runway Width: 45 meters
Surface: Asphalt concrete

Airport Layout

The following layout was taken from the current Aeronautical Information Publication (AIP) Volume II.

Yakarta airport

Figure 5: The Halim Perdanakusuma International Airport layout

The pilots stated that the lightings on the turning pad were bright. The investigation received a photo showing the lightings condition taken on 20 November 2015 on turn pad by a flight crew when aircraft was lining up on runway 24.

Yakarta airport (2)

Figure 6: View from Cockpit on Line up position runway 24

Flight Recorders

Towed Aircraft Flight Recorders

The aircraft was towed without electrical supply, therefore, there was no data recorded by the FDR and CVR related to this accident.

ID 7703 Flight Recorders

Flight Data Recorder

The FDR was successfully downloaded at KNKT facility. The downloaded data was between 1256 UTC until the aircraft stopped at 1258 UTC. 22

The relevant parameter of the occurrence was as follow:

Batik 738 -FDR

Figure 7: The significant parameter recorded by the FDR

The significant parameters recorded by the FDR indicated in the circles and numbers are the following numbers below:

  1. The auto brake activated just after the impact.
  2. The thrust reversers deployed after the impact.
  3. The highest longitudinal acceleration in G’s shows impact event.
  4. The rudder pedal shows positive value, it indicates that the aircraft moved to the right.
  5. The control wheel shows negative value, it indicates the aircraft move left after the impact.
  6. Both brakes pressure indicators show maximum pressure value after impact.
  7. The engine N1’s shows increase to approximate 100% then decreasing suddenly after the impact.
  8. The aircraft speed increase to approximate 14 knots then decreased after the impact.

The Significant Communication from Cockpit Voice Recorder

The excerpt below was the significant communication from 12:45:30 UTC until12:59:57 UTC. Note:

P1: PIC

P2: SIC

FA: flight attendant

BTK: ID 7703 pilot

TWR: Halim Tower controller

DEP1: departure traffic on parking stand B-5 under control by Halim Tower controller

DEP2: departure traffic on parking stand B-7 under control by Halim Tower controller

LDG 1: the first landing traffic under control by Halim Tower controller

LDG 2: the second landing traffic under control by Halim Tower controller

RAAS: Runway Awareness and Advisory System

Time (UTC) From To Communication
12:45:30 TWR BTK Issued pushback clearance
12:48:11 P2 TWR Reported ready for taxi
12:48:14 TWR BTK Issued taxi clearance
12:48:59 TWR LDG 1 Held landing traffic on taxiway “A” to give way towing-aircraft movement on parking stand B-1
12:49:53 TWR BTK Issued departure clearance
12:50:11 TWR BTK Held ID 7703 on taxiway “C” due to another landing traffic (LDG 2)
12:51:17 TWR LDG 1 Instructed to continue slow down taxi from taxiway “A” as the towing aircraft just leaving parking stand B-1
12:52:23 TWR DEP 1 Held the departure traffic on parking stand B-5 (DEP 1) for pushing back
12:52:29 TWR BTK Issued clearance for continuing backtrack runway 24 after LDG 2 landed and passed taxiway “C”
12:53:46 TWR DEP 2 Held another departure traffic on parking stand B-7 (DEP 2) for pushing back

FINDINGS

According to factual information during the investigation, the initial findings and listed as follows:

  1. The B737-800NG aircraft flight number ID 7703 was airworthy prior to the occurrence.
  2. The ID 7703 crew and the air traffic controllers have valid licenses and medical certificates.
  3. Prior to handling the towed aircraft, the towing car driver has handled another aircraft which was towed from north apron via taxiway “C” and “G” then parked at the south apron.
  4. The ATR 42-600 registered PK-TNJ was being moved from north to south apron using a towing car which was via taxiway “C” and planned via taxiway “G”.
  5. The towed aircraft was towed without aircraft electrical, therefore, all navigation lights, strobe lights, and the radio communication were not active.
  6. The ID 7703 pilots conducted the communication with the Halim tower controller at frequency 118.6 MHz and the towing car driver conducted the communication to the Halim tower using a handheld radio with the frequency 152.7 MHz.
  7. The ID 7703 pilots did not know that there was a towing aircraft behind.
  8. The Halim tower instructed towing car driver to expedite the towing and to follow ID 7703 several times.
  9. When ID 7703 was on rolling takeoff at approximate 80 knots, the SIC saw an object. The PIC took over control and applied the right rudder towards the right side of he runway centerline and intended to reject the takeoff, shortly after the pilot felt an impact. The pilot then executed the reject takeoff procedure.
  10. The ID 7703 stopped at approximately 400 meters from the towed aircraft which stopped at the left of the runway 24 centerline at approximately 100 meters from taxiway “G”.
  11. The PIC noticed fire on the left wing tip and immediately shut down both engines, activated the fire extinguishers of both engines and Auxiliary Power Unit (APU) and commanded to the flight attendant “evacuation from the right”.
  12. The Rescue and Fire Fighting Service (RFFS) arrived in the occurrence site within two minutes after crash bell activation and discharged extinguishing agent foam to the left wing of ID 7703 and the other foam tender extinguished the fire on the towed aircraft.
  13. All passengers of ID 7703 were evacuated using escape slide and no one injured in this occurrence.
  14. The pilots realized that the impacted object was an aircraft being towed after they disembarked the aircraft.
  15. The air traffic controller set crew realized that the towed aircraft was on the runway and collided with ID 7703 after asked to the towing car driver.
  16. The assistant noticed the last position of the towed aircraft was when the aircraft abeam the tower building. The assistant did not recall any visible light of towed aircraft except the light from the towing car.
  17. The lights in the tower cab were illuminated and there were several lights reflection on the tower glass windows including the view to the direction of the beginning runway 24.
  18. The pilot stated that during line up, the lights surround the turn pad were very bright and affected his forward vision for a short time.
  19. The published Aeronautical Information Publication (AIP) Volume I Amendment 28, Halim has the runway length of 3,000 meters and was displaced 200 meters.
  20. The investigation could not find Standard Operation Procedure that required a towing aircraft operator communication to the controller on the same frequency used for aircraft movement.

SAFETY ACTION

At the time of issuing this preliminary investigation report, the Komite Nasional Keselamatan Transportasi (KNKT) had been informed of safety actions resulting from this occurrence by the operators.

The KNKT also had been informed several corrective actions responding to the KNKT safety recommendations issued prior to publishing this preliminary report.

PT. Batik AirIndonesia

The safety actions conducted by PT. Batik Air Indonesia related to runway incursion mitigation, ground movement precaution and black out vision recovery.

The summaries of the safety action are as follows:

On 7 April 2016, issued notice to pilot number 009/IV/2016 described:

Runway Incursion Mitigation Review

According to incursion event PK-LBS Batik Air on April 4th, 2016 here we remind you to review RUNWAY INCURSION refers to Batik Operation Manual Part A Rev: 02 Issued: 02 date March 14th, 2016 Chapter 8.3.1.8 point A, B, C, D, E. Specially point C to mitigate risk as attached on this notice, otherwise to follow company email from Chief Pilot on April 5th, 201 6 about “Requesting Information Ground Traffic” to ATC Halim during before taxing specially night operation.

On 10, April 2016, issued safety circular number 06/SSQ/SC/IV/2016 described:

Based on PK-LBS serious incident, SSQ Directorate emphasis all operation staff to always implement all tasks in accordance with Standard Operating Procedure (SOP). Besides, SSQ gives safety precaution in ground movement as follows:

  1. Pilot:
  2. Ensure ground traffic before and during taxi
  3. Performed visual check of runway and traffic condition before entering to the active runway

iii. To ensure the runway was clear before takeoff

  1. In any doubt of traffic, contact the ATC controller before continue movement
  2. Ground Handling
  3. Coordinate with the pilot to ensure the traffic status before push back
  4. Always communicate with the same frequency with ATC controller in any towing aircraft

iii. Ensure that clearance had been approved by ATC controller before push back or towing the aircraft

  1. Use the same frequency with ATC controller in any movement of towing car in the maneuvering area
  2. FOO
  3. To monitor the aircraft and traffic movement on the ground and air.
  4. In any problem regarding the traffic or movement, contact the Aircraft Movement Control (AMC) or related department to find problem-solving.

On 18 April 2016, issued notice to pilot number 010/IV/2016 described:

Delay for Takeoff for due to Black out Vision Recovery

In regard the condition of a night take off on runway 24 and to avoid black out in vision caused by high intensity of approach light in dark environment during turning in to position on runway 24 Halim Perdanakusuma, pilot required to delay the take off until the eyes back to normal adaptive environment before call ready for departure.

PT. TransNusa Aviation Mandiri

On 14 April 2016, PT. TransNusa Aviation Mandiri informed to the Komite Nasional Keselamatan Transportasi related to safety action taken as follows:

  1. Issued Safety Notice number SN/001-IV/2016 dated 7 April 2016 described:
  2. Improve the situational awareness for all pilots especially during takeoff and landing at Halim Perdanakusuma and other airports.
  3. To use the same active frequency during movement in the maneuvering area.
  4. Engineer requires using VHF handheld radio as a backup communication during towing.
  5. To conduct the towing procedure refreshing course for all engineers.
  6. To include the towing procedure from Aircraft Maintenance Manual (AMM) in the TransNusa Aviation Mandiri (TAM) procedure.
  7. To conduct any task according to approved procedures.
  8. Issued notice to pilot number 002/OPS/TAM/IV/2016 dated 7 April 2016, described:
  9. To ensure the runway is clear from any traffic, animal or foreign object after receiving takeoff clearance from air traffic controller.
  10. Improve the awareness of any obstacle during taxi.
  11. To follow the air traffic controller instruction and recheck prior to executing any instruction.
  12. Issued Quality Notice number QN-TAM/018/IV/2016 dated 11 April 2016, described:
  13. During pushback and towing, the engineer must refer to Aircraft Maintenance Manual (AMM) Chapter 9 on each aircraft type, especially to switch “ON” the Navigation and Anti- Collision Light (by night only).
  14. If towing is performed with the unavoidable deviation from the AMM due to the specific reason, the engineer must refer to the approved internal documents issued by Quality or Technical Service such as Quality Instruction or Engineering Instruction.
  15. ATC permission to tow must be obtained by the engineer in charge who sit in the cockpit using VHF Comm which installed on the aircraft with normal ATC frequency. In the case of the certain airport, the communication is required only between ground handling and ATC using the specific frequency, the engineer should monitor in the normal ATC frequency by the VHF Com on the aircraft or GH operator.
  16. The engineer should refuse to start towing when any other aircraft is still on the runway. If AMC forces the aircraft to enter the runway and coincides with the other aircraft, the engineer should request “follow me” car to guide the aircraft passing clear of the runway.

AirNav Indonesia

Responding to KNKT safety recommendation the AirNav Indonesia issued safety notice addressed to all air traffic control units as follows:

  1. Required all towing aircraft to switch on the navigation lights.
  2. Required all towing aircraft to communicate in published tower frequency.
  3. Required all vehicle without radio communication entering maneuvering area shall be guided by “follow me car”.
  4. Required air traffic controller to record towing movement on the flight progress strip.
  5. Required to reduce the lights intensity in the tower cab while providing air traffic services at night.

SAFETY RECOMMENDATIONS

Referring to the initial information, the Komite Nasional Keselamatan Transportasi had issued safety recommendations number KNKT/001/IV/REK.KU/2016 on 7 April 2016 to address the identified safety issues. The recommendations were as follows:

AirNav Indonesia District Office Halim Perdanakusuma

04.A-2016-51.1

To develop procedures for all aircraft movement on the maneuvering area including the aircraft movement without aircraft own power, to communicate with air traffic controller on the same frequency.

04.A-2016-52.1

To evaluate the current lighting of tower cab to prevent glare that may distract controller view.

04.A-2016-53.1

To remind the ATC controller to maintain continues watch the aircraft movement on the maneuvering area, especially when issued air traffic control clearance.

AirNav Indonesia District Office Halim Perdanakusuma and Angkasa Pura II Brach Office Halim Perdanakusuma International Airport

04.B-2016-54.1

To develop procedures for vehicle and aircraft on the maneuvering area shall be equipped with serviceable lights visible by air traffic controller.

On 26 April 2016, KNKT issued additional safety recommendation number KNKT/002/IV/REK.KU/2016 as follows:

04.B-2016-57.1

To inform the aircraft operators to initiate takeoff from the threshold runway 24 of Halim Perdanakusuma International Airport

Directorate General of Civil Aviation

04.R-2016-55.1

To review a requirement for all aircraft movement on the maneuvering area including the aircraft movement without aircraft own power, to communicate with air traffic controller on the same frequency.

04.A-2016-56.1

To develop procedures for vehicle and aircraft on the maneuvering area shall be equipped with serviceable lights visible by air traffic controller.

Excerpted from Republic of Indonesia KOMITE NASIONAL KESELAMATAN TRANSPORTASI Aircraft Accident Investigation Report PRELIMINARY KNKT.16.04.07.04, 4 April 2016 http://kemhubri.dephub.go.id/knkt/ntsc_home/ntsc.htm

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