SU95, manoeuvring near Jakarta Indonesia,

2012 (CFIT HF FIRE)

Category: Accidents and Incidents
Summary
On 9 May 2012, a Sukhoi RRJ-95 on a manufactureroperated demonstration flight out of Jakarta descended
below the promulgated safe altitude and, after TAWS
alerts and warnings had been ignored, impacted terrain
in level flight which resulted in the destruction of the
aeroplane and death of all 45 occupants. The
Investigation concluded that that the operating crew
were unaware that their descent would take them below
some of the terrain in the area until the alerts started and
then assumed they had been triggered by an incorrect
database and switched the equipment off.

Event Details
May 2012

When
Event Type

CFIT, FIRE, HF

Day/Night

Day

Flight Conditions

IMC

Flight Details
Aircraft

SUKHOI Superjet 100-95

Operator

Private

Type of Flight
Origin

Public Transport (Non Revenue)

Jakarta/Halim Perdanakusuma

Intended Destination Jakarta/Halim Perdanakusuma

Flight Phase

Cruise
ENR

Location
Approx.

Mt. Salak, Indonesia

General
Inadequate Aircraft Operator Procedures
Tag(s) Inadequate ATC Procedures
Ineffective Regulatory Oversight

CFIT

Tag(s)

Into terrain
No Visual Reference
Lateral Navigation Error
Vertical navigation error
IFR flight plan

FIRE
Tag(s)

Post Crash Fire

HF

Tag(s)

Distraction
Ineffective Monitoring
Manual Handling
Procedural non compliance

Safety Net Mitigations

Malfunction of Relevant Safety No

Net
Available but
ineffective

TAWS

Outcome
Damage or injury

Yes

Aircraft damage

Hull loss
Most or all occupants

Fatalities

Causal Factor Group(s)

Aircraft Operation
Air Traffic Management

Group(s)

Safety Recommendation(s)

Group(s)

Aircraft Operation
Aircraft Airworthiness
Air Traffic Management
Airport Management

Investigation Type
Type

Independent

Description
On 9 May 2012, an Sukhoi Superjet RRJ95 being operated by the aircraft manufacturer on a
daylight demonstration flight out of Jakarta on an IFR Flight Plan filed for flight at 10000 feet
with an estimated flight time of 30 minutes asked for and was approved for descent to 6000 feet
shortly after reaching 10000 feet and was found the following day to have impacted terrain near
the summit of Mount Salak in IMC at 6000 feet causing the destruction of the aircraft and the
deaths of all 45 occupants.

Investigation
An Investigation was carried out by the NTSC aided by location, recovery and successful replay
of both the two hour CVR and FDR.

It was noted that the accident flight was the second of two that day using a flight crew consisting
of two pilots with a navigator, flight test engineer and engine manufacturers representative on
board. The flight path of both flights is shown on the diagram below taken from the Investigation
Report. The aircraft commander had been acting as PF for the accident flight and a representative
of a potential customer had been occupying the flight deck observer seat. It was found that the
charts carried on board the aircraft did not appear to include ones which would have contained
information on the terrain in the area where the descent prior to impact was made.

The tracks flown by both demonstration flights with the accident flight shown in yellow
(reproduced from the Official Report)
Four minutes after take off, ATC had been advised that the aircraft had reached 10000 feet and
two minutes after that, a request for descent to 6,000 feet was passively acknowledged by ATC.
Two minutes after that, the crew requested a right hand orbit at 6000 feet which was approved by
ATC. Just over three minutes later, a succession of TAWS activations had occurred over a period
of 18 seconds. First had been a single TERRAIN AHEAD, PULL UP Warning which was
almost immediately followed by a rapid succession of six AVOID TERRAIN Alerts
immediately after which the aircraft commander had inhibited the TAWS system assuming that
the warning was a problem on the database. Shortly after this and seven seconds before impact,
which occurred twelve minutes after take off in IMC in level flight at an altitude of
approximately 6000 feet, a Flight Warning System audio alert LANDING GEAR NOT
DOWN had also activated. The evidence suggested that although the TAWS terrain map display
had been briefly demonstrated only a few minutes earlier, it had only been selected on for that

demonstration, which had taken place with the aircraft heading away from high terrain, before
being selected off again. The crash site was 28 DME from Jakarta Airport.
FDR data showed that the orbit had been conducted as a means to lose height in preparation for
the return to land and had been accomplished with the AP engaged using progressive movement
of the heading selector with the aim of bringing the aircraft through 360 onto the starting
heading prior to setting course to begin the approach. However, FDR and CVR data showed that
whilst the attention of the PF was distracted with conversation not related to the progress of the
flight, the aircraft had exited the orbit with 26 to go and possibly without either pilot
appreciating this. Soon after rolling wings level, the aircraft exceeded a 25 DME from the airport
and continued on the same heading until shortly before impact.
The applicable AIP-published Minimum Sector Altitude (MSA) which applied within 25nm of
the airport was found to be 6900 feet but the en-route chart which applied beyond that to any
flight operating off designated airways, which the accident aircraft was, indicated an Area
Minimum Altitude (AMA) of 13200 feet.
The Investigation noted that MSAW was available to ATC and was equipped with both a Terrain
Conflict Alert (TR), triggered if any aircraft altitude reached or went below the applicable MSA
and a Predicted Terrain Conflict Alert (PTR) triggered if an aircraft began to approach the
applicable MSA. The PTR Alert activated a flashing yellow label PTR and the TR Alert was
able to activate a flashing red label TR and an aural alarm, however the latter had been
deactivated. In any case, although the system was found to be set up to activate in respect of
obstacles such as the tops of some mountains in the area, the terrain information for the area of
Mount Salak had not been inserted into the system and minimum radar vectoring altitudes had
not been comprehensively established.
The Investigation found the radar controller involved had checked his Flight Data Edit Display
and understood from it that the aircraft on the flight was a Su-30, a military fighter aircraft, and
thereby assumed that it was a test flight to the area filed on the flight plan and might be expected
to then make use of the designated military exercise area at that location between GND and 6000
feet. It was noted that the workload of this controller involved had been high with almost
continuous transmissions with up to 14 aircraft without the benefit of an assistant or a
supervisory presence.
The FDR data was used to reproduce the accident flight using test pilots in a Sukhoi aircraft type
simulator. This concluded that if prompt and prescribed recovery action had been initiated within
24 seconds of the first TAWS warning, terrain impact could have been avoided.
The Investigation formally identified the following Causal Factors in respect of the Accident:

The flight crew was not aware of the mountainous area in the vicinity of the flight path
due to various factors such as available charts, insufficient briefing and statements of the
potential customer that resulted in inappropriate response to the TAWS warning. The
impact could have been avoided by appropriate action of the pilot up to 24 seconds after
the first TAWS warning.

The Jakarta Radar service had not established the minimum vectoring altitudes and the
Jakarta Radar system was not equipped with functioning MSAW for the particular area
around Mount Salak.

Distraction of the flight crew from prolonged conversation not related to the progress of
the flight, resulted in the pilot flying not constantly changing the aircraft heading while in
orbit. Consequently, the aircraft unintentionally exited the orbit.

A series of Safety Actions arising from the accident and undertaken by the DGCA, the ANSP
and the aircraft operator during the course of the Investigation were noted.
Fourteen Safety Recommendations were made as a result if the Investigation as follows:

that the Indonesian Directorate General of Civil Aviation review its oversight and to
ensure flight crew actions to respond properly the aircraft system warning through
adequate training

that the Indonesian Directorate General of Civil Aviation ensure that all aircraft
operated under IFR should be conducted with respect to a published minimum safe flight
altitude

that the Indonesian Directorate General of Civil Aviation review its oversight and to
ensure that all ATS provider comply with the requirement of MSAW and the minimum
vectoring altitude being integral part of radar service

that the Indonesian Directorate General of Civil Aviation review its oversight and to
ensure that all ATS provider follow with the requirement of Advisory Circular (AC) 17002 regarding Capacity Management

that the Indonesian Directorate General of Civil Aviation review its oversight and to
ensure that all approved Ground Handling comply with regulatory documentation
keeping in regard to crew and passenger manifest.

that the Jakarta International Airport ensure that the ATC units and airspace structure
provide acceptable workload for the ATC as on Advisory Circular (AC) 170-02 regarding
Capacity Management

that the Jakarta International Airport ensure its radar warning system functions
properly and to review that all radar controllers are fully conversant with the system and
comply with procedures that they operate

that the Jakarta International Airport ensure that the correct aircraft type data to be
entered to the Flight Data Edit Display (FDED)

that the Department of Aviation Industry of the Russian Ministry of Trade and
Industry review its oversight and ensure flight crew actions to respond properly (to) the
aircraft system warning through adequate training

that the Department of Aviation Industry of the Russian Ministry of Trade and
Industry ensure that all aircraft operated under IFR should be conducted with respect to
a published minimum safe flight altitude

that the 'Department of Aviation Industry of the Russian Ministry of Trade and
Industry review the current procedures for the preparation and conduct of a
demonstration flight and, if needed, introduce appropriate amendments

that the Department of Aviation Industry of the Russian Ministry of Trade and
Industry provide the crews with sufficient aeronautical information

that the Sukhoi Civil Aircraft Company provide the crews with sufficient aeronautical
and other necessary information to the crew member prior to perform(ing) flight outside
published airway(s) including obstacle and terrain information

that the Sukhoi Civil Aircraft Company review its current demonstration flight
practices and ensures the compliance to the flight procedures during demonstration flight

The Final Report of the Investigation KNKT.12.05.09.04 was released on 18 December 2012.