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Last updated: 27 October 2021
Status:Final
Date:Monday 14 September 2009
Type:Silhouette image of generic DHC6 model; specific model in this crash may look slightly different
de Havilland Canada DHC-6 Twin Otter 300
Operator:Aviastar Mandiri
Registration: PK-BRS
MSN: 299
First flight: 1971
Total airframe hrs:41904
Cycles:93939
Engines: 2 Pratt & Whitney Canada PT6A-27
Crew:Fatalities: 0 / Occupants: 2
Passengers:Fatalities: 0 / Occupants: 10
Total:Fatalities: 0 / Occupants: 12
Aircraft damage: Substantial
Location:Serui-Sudjarwo Tjondronegoro Airport (ZRI) (   Indonesia)
Phase: Landing (LDG)
Nature:Domestic Scheduled Passenger
Departure airport:Biak-Frans Kaisiepo Airport (BIK/WABB), Indonesia
Destination airport:Serui-Sudjarwo Tjondronegoro Airport (ZRI/WABO), Indonesia
Narrative:
The DHC-6 Twin Otter, registered PK-BRS, operated under Visual Flight Rules (VFR) on a scheduled passenger service from Biak-Frans Kaisiepo Airport, to Serui.
The first officer who occupied left hand seat acted as Pilot Flying (PF) and the pilot in command occupied who right hand seat was a training captain (instructor), acting as Pilot
Monitoring (PM). The first officer's first flight to Serui was on 11 September 2009 and was the check flight to be qualified first officer. This flight was the first landing accomplished from the left seat.
While approaching Serui Airport, the pilot received information that the wind direction was 150° to 200° and velocity 15 up to 20 knots. This wind figure has a cross wind component up to 10 knots from the right and tail wind component of 12-16 knots. The aircraft landed with flap at 20° and the target threshold speed was 87 knots. The training captain noticed that on final approach, the aircraft speed was higher than the target, which he announced.
The normal operation at Serui is for takeoffs to use runway 18 and landings to use runway 36. This is caused by high terrain on the north side of the airport. The aircraft landed on runway 36.
Prior to touch down the aircraft floated over the runway and on landing roll the aircraft drifted to the right. At a speed of approximately 40 knots, the aircraft then drifted to the right, the first officer countered the situation by right rudder but could not manage the aircraft back to centreline.
The right main wheel ran out of the runway. The first officer then tried to correct the situation by applying nose wheel steering. The aircraft then experienced a ground loop and stopped at 90°
relative to the runway.
During the ground loop the forward inertia in combination with the tail wind component caused the left wing to be lifted up and the right wing tip and right engine propeller touched the runway. The forward inertia also collapsed the nose landing gear to 120° to the left relative to the aircraft longitudinal axis.
The pilot then shut down both engines and commanded to the passengers to evacuate. No one was injured in this accident. The aircraft has substantial damage. The DHC-6 Twin Otter, registered PK-BRS, operated under Visual Flight Rules (VFR) on a scheduled passenger service from Biak-Frans Kaisiepo Airport, to Serui.
The first officer who occupied left hand seat acted as Pilot Flying (PF) and the pilot in command occupied who right hand seat was a training captain (instructor), acting as Pilot
Monitoring (PM). The first officer's first flight to Serui was on 11 September 2009 and was the check flight to be qualified first officer. This flight was the first landing accomplished from the left seat.
While approaching Serui Airport, the pilot received information that the wind direction was 150° to 200° and velocity 15 up to 20 knots. This wind figure has a cross wind component up to 10 knots from the right and tail wind component of 12-16 knots. The aircraft landed with flap at 20° and the target threshold speed was 87 knots. The training captain noticed that on final approach, the aircraft speed was higher than the target, which he announced.
The normal operation at Serui is for takeoffs to use runway 18 and landings to use runway 36. This is caused by high terrain on the north side of the airport. The aircraft landed on runway 36.
Prior to touch down the aircraft floated over the runway and on landing roll the aircraft drifted to the right. At a speed of approximately 40 knots, the aircraft then drifted to the right, the first officer countered the situation by right rudder but could not manage the aircraft back to centreline.
The right main wheel ran out of the runway. The first officer then tried to correct the situation by applying nose wheel steering. The aircraft then experienced a ground loop and stopped at 90°
relative to the runway.
During the ground loop the forward inertia in combination with the tail wind component caused the left wing to be lifted up and the right wing tip and right engine propeller touched the runway. The forward inertia also collapsed the nose landing gear to 120° to the left relative to the aircraft longitudinal axis.
The pilot then shut down both engines and commanded to the passengers to evacuate. No one was injured in this accident. The aircraft has substantial damage.

Probable Cause:

Contributing factors: "The decision making process was not well performed where less experience pilot handling the aircraft in a the high risk situation such as one way landing operation and wind condition lead to excessive operation of the nose wheel steering during the veer recovery."

Accident investigation:
cover
Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 5 years and 7 months
Accident number: KNKT.09.10.16.04
Download report: Final report


Follow-up / safety actions

NTSC issued 4 Safety Recommendations

Show all...

Photos

photo of DHC-6-300-Twin-Otter-PK-BRS
accident date: 14-09-2009
type: de Havilland Canada DHC-6-300 Twin Otter
registration: PK-BRS
photo of DHC-6-300-Twin-Otter-PK-BRS
accident date: 14-09-2009
type: de Havilland Canada DHC-6-300 Twin Otter
registration: PK-BRS
 

Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Biak-Frans Kaisiepo Airport to Serui-Sudjarwo Tjondronegoro Airport as the crow flies is 77 km (48 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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