Investigation Summary
The flight departed Berau at 02:30 UTC and proceeded normally until the final approach to Samarinda. During the approach, the crew observed a left Engine Control Unit (ECU) light, followed by low oil pressure and torque indications on the left engine. The Pilot in Command (PIC) initiated a go-around and elected to divert to Balikpapan, approximately 16 nautical miles away, while performing the engine shutdown procedure. While climbing through 3,800 feet toward Balikpapan, the right engine exhibited identical failure symptoms (ECU light, low oil pressure, and low torque) and subsequently flamed out. With no power remaining, the crew broadcast a MAYDAY and executed a forced landing in a clear field. The investigation by the NTSC was significantly hampered because both the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were found to be non-functional at the time of the accident, preventing a definitive analysis of the crew's fuel management and the exact nature of the engine failures.
Final Conclusions
The investigation concluded that both engines flamed out due to fuel exhaustion. The primary contributing factor was identified as fuel management that was 'out of control' during the flight, which may have been influenced by misleading fuel quantity indications. The NTSC noted that a proper technical analysis of the crew's actions and system behavior was impossible because the FDR and CVR were inoperative.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
First Officer
Systems & Failure Modes
Fuel Quantity Indication System
Investigators suspected the crew may have been misled by inaccurate fuel readings, leading to fuel exhaustion.
Flight Recorders (FDR/CVR)
Both recorders were found to be non-functional, preventing a detailed analysis of the engine failures and crew communication.
Engine Control Unit (ECU)
ECU warning lights preceded the loss of power and oil pressure in both engines.
Interesting Facts
- 01All 52 people on board (46 passengers and 6 crew) survived the forced landing.
- 02Both the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were inoperative during the flight.
- 03The aircraft was an ATR 42-300 manufactured in 1987 with 34,414 flight hours.
- 04The investigation found the engines flamed out due to a lack of fuel reaching the engines.
- 05Two passengers suffered serious injuries during the emergency evacuation.
Safety Actions & Advisories
Flight Recorder Maintenance
The NTSC emphasized the requirement for operators to ensure that Flight Data Recorders and Cockpit Voice Recorders are fully functional before flight, as their failure in this accident prevented a full technical analysis of the engine flameouts.
Fuel Management Oversight
The investigation highlighted the need for improved fuel management procedures and pilot training regarding fuel quantity monitoring, especially when operating aircraft with potential indication discrepancies.
Location
APPROXIMATE POSITION · AIRPORT LEVEL · Coordinates are the estimate published in the official investigation report. The ring shows the accuracy the record supports, not the point of impact.