Investigation Summary
The flight was a non-scheduled passenger service operating under Visual Flight Rules (VFR). Shortly after departure from Medan, the crew requested a direct route to a waypoint named PAPA and climbed to 8,000 feet. Despite the VFR requirement to remain clear of clouds, Cockpit Voice Recorder (CVR) analysis revealed that both pilots agreed to enter cloud cover. This decision led to a total loss of visual references. The investigation highlighted a steep cockpit transition gradient, where the First Officer, a former Indonesian Army pilot, did not effectively challenge the Captain's decisions. Furthermore, the crew failed to perform standard checklist readings or a pre-flight briefing. The aircraft was equipped with an Emergency Locator Transmitter (ELT) which successfully triggered, allowing search teams to locate the wreckage the following day. The Indonesian government briefly suspended the airline's Air Operator Certificate (AOC) following the accident, grounding the fleet while safety measures were reviewed.
Final Conclusions
The National Transportation Safety Committee (NTSC) concluded the accident was a Controlled Flight Into Terrain (CFIT). The primary cause was the crew's decision to continue flying into weather conditions below VFR minima, leading to a loss of situational awareness. Contributing factors included a lack of crew coordination due to a steep cockpit transition gradient and the omission of required checklists and briefings. The NTSC also noted that the crew had not received specific CFIT or Approach and Landing Accident Reduction (ALAR) training.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
First Officer
Former Indonesian Army pilot.
Systems & Failure Modes
Emergency Locator Transmitter (ELT)
A device designed to transmit a distress signal upon impact; the unit on PK-TLF functioned correctly, allowing rescuers to find the site.
Cockpit Voice Recorder (CVR)
A flight recorder used to record the audio environment in the flight deck; analysis confirmed the pilots agreed to fly into clouds.
Interesting Facts
- 01The aircraft was a CASA C-212-200 Aviocar manufactured in 1989.
- 02The flight was conducted under Visual Flight Rules (VFR) but entered clouds.
- 03The wreckage was found 16 nautical miles from the destination airport, Kutacane.
- 04All 18 occupants, including two children and two infants, were killed in the impact.
- 05The Captain had 3,730 hours of experience on the CASA C-212 type.
Safety Actions & Advisories
AOC Suspension
The Indonesian Government suspended Nusantara Buana Air's air operator's certificate immediately following the crash, grounding the fleet.
Training Mandates
The NTSC recommended the Indonesian Directorate General Civil Aviation improve supervision and ensure pilots receive CFIT and ALAR training.