Aircraft Serious Incident Investigation Report AIRBUS A321 PK–YVE

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TRANSPORTATION
SAFETY
COMMITTEE
Aircraft Serious Incident Investigation Report

ISBN:
When the NTSC makes recommendations as a result of its
investigations or research, safety is its primary consideration.
However, the NTSC fully recognizes that the implementation of
recommendations arising from its investigations will in some cases
incur a cost to the industry.
Readers should note that the information in NTSC reports and
recommendations is provided to promote aviation safety. In no case
is it intended to imply blame or liability.
This report was produced by the National Transportation Safety
Committee (NTSC), Karya Building 7th Floor Ministry of
Transportation, Jalan Medan Merdeka Barat No. 8 JKT 10110,
Indonesia.
The report is based upon the investigation carried out by the NTSC in
accordance with Annex 13 to the Convention on International Civil
Aviation, Aviation Act (UU No.1/2009), and Government Regulation
(PP No. 3/2001).
Readers are advised that the NTSC investigates for the sole purpose of
enhancing aviation safety. Consequently, NTSC reports are confined to
matters of safety significance and may be misleading if used for any
other purpose.
As NTSC believes that safety information is of greatest value if it is
passed on for the use of others, readers are encouraged to copy or
reprint for further distribution, acknowledging NTSC as the source.

i
TABLE OF CONTENTS
TABLE OF CONTENTS....................................................................................................... i
TABLE OF FIGURES ......................................................................................................... iii
GLOSSARY OF ABBREVIATIONS.................................................................................. iv
SYNOPSIS ............................................................................................................................. 1
1. FACTUAL INFORMATION................................................................................... 2
1.1 History of the Flight ......................................................................................................2
1.2 Injuries to Persons..........................................................................................................5
1.3 Damage to aircraft .........................................................................................................5
1.4 Other damage.................................................................................................................5
1.5 Personnel information ...................................................................................................5
1.5.1 Pilot in command ...................................................................................................5
1.5.2 Copilot ...................................................................................................................6
1.6 Aircraft Information ......................................................................................................7
1.6.1 Aircraft Data ..........................................................................................................7
1.6.2 Engine Data ...........................................................................................................7
1.6.3 Weight and Balance...............................................................................................8
1.6.4 Maintenance...........................................................................................................8
1.7 Meteorological Information...........................................................................................8
1.8 Aids to Navigation .........................................................................................................8
1.9 Communications ............................................................................................................8
1.10 Aerodrome Information .................................................................................................9
1.10.1 General...................................................................................................................9
1.11 Flight Recorders.............................................................................................................9
1.11.1 Digital Flight Data Recorder (DFDR) ...................................................................9
1.11.2 Cockpit Voice Recorder (CVR) ............................................................................9
1.11.3 Notable facts from the CVR..................................................................................9
1.11.4 FDR Readout.......................................................................................................10
1.12 Wreckage and impact information...............................................................................10
1.13 Medical and Pathological Information .........................................................................11
1.14 Fire..............................................................................................................................11
1.15 Search and survival aspects..........................................................................................11
1.16 Test and Research ........................................................................................................11
1.17 Organizational and Management Information..............................................................12
ii
1.17.1 Batavia Air ..........................................................................................................12
1.18 Additional Information ................................................................................................12
No additional information relevant to the occurrence. .....................................................12
2. ANALYSIS............................................................................................................... 13
3. CONCLUSION........................................................................................................ 15
3.1 Findings .......................................................................................................................15
4. SAFETY RECOMMENDATIONS ....................................................................... 16
4.1 Recommendation to Batavia Air ...............................................................................16
4.2 Recommendation to Directorate General Civil Aviation.........................................16
iii
TABLE OF FIGURES
Figure 1: PK-YVE, Batavia Air Airbus A320 at Medan on 2 June 2008 ............................... 2
Figure 2: Touch down tire marks on touch down area............................................................ 4
Figure 3: Rolling tire marks on runway up to final stop at adjacent to taxi way D ................ 4
Figure 4: Wheel number 1....................................................................................................... 5
Figure 5: Broken left landing gear down lock cable ............................................................... 8
Figure 6: Tire mark on runway close to taxi way D.............................................................. 10
Figure 7: Tire number 1 and number 2 marks....................................................................... 11
Figure 8: Tire number 3 mark ............................................................................................... 11
Figure 9: Touch down number 1 and number 2 tire marks ................................................... 11
iv
GLOSSARY OF ABBREVIATIONS
AD Airworthiness Directive
AFM Airplane Flight Manual
AGL Above Ground Level
ALAR Approach-and-landing Accident Reduction
AMSL Above Mean Sea Level
AOC Air Operator Certificate
ATC Air Traffic Control
ATPL Air Transport Pilot License
ATS Air Traffic Service
ATSB Australian Transport Safety Bureau
Avsec Aviation Security
BMG Badan Meterologi dan Geofisika
BOM Basic Operation Manual
CAMP Continuous Airworthiness Maintenance Program
CASO Civil Aviation Safety Officer
CASR Civil Aviation Safety Regulation
CPL Commercial Pilot License
COM Company Operation Manual
CRM Cockpit Recourses Management
CSN Cycles Since New
CVR Cockpit Voice Recorder
DFDAU Digital Flight Data Acquisition Unit
DGCA Directorate General of Civil Aviation
DME Distance Measuring Equipment
EEPROM Electrically Erasable Programmable Read Only Memory
EFIS Electronic Flight Instrument System
EGT Exhaust Gas Temperature
EIS Engine Indicating System
FL Flight Level
F/O First officer or Copilot
FDR Flight Data Recorder
FOQA Flight Operation Quality Assurance
GPWS Ground Proximity Warning System
Hrs Hours
ICAO International Civil Aviation Organization
IFR Instrument Flight Rules
IIC Investigator in Charge
5
ILS Instrument Landing System
Kg Kilogram(s)
Km Kilometer(s)
Kts Knots (NM/hour)
Mm Millimeter(s)
MTOW Maximum Take-off Weight
NM Nautical mile(s)
KNKT / NTSC Komite Nasional Keselamatan Transportasi / National
Transportation Safety Committee
°C Degrees Celsius
PIC Pilot in Command
QFE Height above aerodrome elevation (or runway threshold elevation)
based on local station pressure
QNH Altitude above mean sea level based on local station pressure
RESA Runway End Safety Area
RPM Revolution Per Minute
SCT Scattered
S/N Serial Number
SSCVR Solid State Cockpit Voice Recorder
SSFDR Solid State Flight Data Recorder
TS/RA Thunderstorm and rain
TAF Terminal Aerodrome Forecast
TSN Time Since New
TT/TD Ambient Temperature/Dew Point
TTIS Total Time in Service
UTC Coordinated Universal Time
VFR Visual Flight Rules
VMC Visual Meteorological Conditions

1
SYNOPSIS
On 1 June 2008, an Airbus A320 aircraft, registration PK-YVE, was being
operated by Metro Batavia Airlines (Batavia Air) flight number 7P-591, on a
scheduled passenger flight from Jakarta to Medan. The flight departed at 00:10 UTC
(07:10 local time) with an estimated arrival time at Medan of 02:25. There were 140
people on board; two pilots, five cabin crew, and 133 passengers.
The aircraft touched down towards the departure end of the touch-down area of
runway 05 at Polonia Airport, Medan at 03:04. After a landing run of 41 seconds, the
aircraft stopped on the runway adjacent to taxiway ‘D’, approximately 1,200 meters
from the estimated point of touch down. Three main-wheel tires and two main
wheels were substantially damaged. The aircraft could not be taxied from the runway
to the apron, nor could it be towed to the apron due to damage to the wheels.
The passengers and crew disembarked normally at taxiway ‘D’; there were no
injuries.
Following an inspection of the landing gear and replacement of the damaged wheels,
the aircraft was towed to the apron at 10:10. The runway was closed for about 7
hours.
The investigation found that the left landing gear down-lock cable was broken. The
aircraft touched down with the wheel brakes locked due to a hydraulic lock in the
system, which was the result of an incorrect manual landing gear extension
procedure being used by the pilots.
The pilots’ actions indicated that they did not sufficiently understand the aircraft’s
landing gear system, resulting in them using inappropriate trouble shooting and
rectification procedures.
The pilots were not sufficiently confident of the aircraft’s fuel state to conduct a go
around and fly past as cleared by ATC.
With the release of the final report, the National Transportation Safety Committee’s
(NTSC) issued two recommendations to address the safety deficiencies identified in
the report. These covered flight crew technical knowledge of aircraft systems, fuel
planning and flight management, and the regulatory oversight of the airline’s training
program.
2
1. FACTUAL INFORMATION
1.1 History of the Flight
On 1 June 2008, an Airbus A320 aircraft, registration PK-YVE, operated by
Metro Batavia Airlines (Batavia Air) as a flight number 7P-591, was being
operated on a scheduled passenger flight from Jakarta to Medan.
The aircraft departed from Soekarno – Hatta Airport, Jakarta at 00:10 Coordinated
Universal Time1 (UTC) (07:10 local time), under the instrument flight rules (IFR).
The estimated time of arrival (ETA) at Polonia Airport, Medan, North Sumatera
was 02:25. The pilot in command (PIC) was the handling pilot and the copilot was
the support/monitoring pilot.

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Aircraft Serious Incident Investigation Report AIRBUS A321 PK–YVE