Mandala Airlines Flight 091
Encyclopedia
On 5 September 2005 a Jakarta
Jakarta
Jakarta is the capital and largest city of Indonesia. Officially known as the Special Capital Territory of Jakarta, it is located on the northwest coast of Java, has an area of , and a population of 9,580,000. Jakarta is the country's economic, cultural and political centre...

-bound Boeing 737-200
Boeing 737
The Boeing 737 is a short- to medium-range, twin-engine narrow-body jet airliner. Originally developed as a shorter, lower-cost twin-engine airliner derived from Boeing's 707 and 727, the 737 has developed into a family of nine passenger models with a capacity of 85 to 215 passengers...

 jetliner operated by Mandala Airlines
Mandala Airlines
Mandala Airlines was a low-cost airline headquartered in the Mandala Airlines Building in West Jakarta, Jakarta, Indonesia. Mandala operated scheduled services to 3 international and 17 domestic destinations, used a fleet of narrow body Airbuses. Its main operational base was Soekarno-Hatta...

crashed into a heavily-populated residential area seconds after taking off from Polonia International Airport
Polonia International Airport
Polonia International Airport is located in the city of Medan, Indonesia, about 5 km from the Central Business District. It is the first international airport in Medan, the other being the planned Kuala Namu International Airport...

 in Medan, Indonesia
Indonesia
Indonesia , officially the Republic of Indonesia , is a country in Southeast Asia and Oceania. Indonesia is an archipelago comprising approximately 13,000 islands. It has 33 provinces with over 238 million people, and is the world's fourth most populous country. Indonesia is a republic, with an...

. There were 143 fatalities.

Dozens of houses and cars were destroyed, and at least 49 people are reported to have perished on the ground. Later it was reported that at least 16 persons survived the accident, with 104 of those on board known to have died including three babies. Most of the survivors are thought to have been seated at the rear of the aircraft, though some have reportedly since died from their injuries. Most of the dead were Indonesian, although at least one Malaysian, Ti Teow Chuan from Sabah
Sabah
Sabah is one of 13 member states of Malaysia. It is located on the northern portion of the island of Borneo. It is the second largest state in the country after Sarawak, which it borders on its southwest. It also shares a border with the province of East Kalimantan of Indonesia in the south...

, was reported dead. Rizal Nurdin
Rizal Nurdin
TNI Major General Haji Tengku Rizal Nurdin was the 14th and 15th Governor of North Sumatra, Indonesia. He served from 1998 until his death on September 5, 2005. In that time he was serving in his second period...

, the governor of North Sumatra
North Sumatra
North Sumatra is a province of Indonesia on the Sumatra island. Its capital is Medan. It is the most populous Indonesian province outside of Java. It is slightly larger than Sri Lanka in area.- Geography and population :...

 at the time, and Raja Inal Siregar
Raja Inal Siregar
Raja Inal Siregar was governor of North Sumatra from 1988 to 1998. He died in the Mandala Airlines Flight 091 crash. He was said to be on his way to talks with Susilo Bambang Yudhoyono at the time....

, the former governor, were among the dead.

The crash was the sixth major incident involving commercial airliners from August 1, 2005 to the date of the incident. The others were, in chronological order: Air France Flight 358
Air France Flight 358
Air France Flight 358, a flight from Paris, France, to Toronto, Canada, using an Airbus A340 airliner, departed Paris without incident at 11:53 UTC 2 August 2005, later touching down on runway 24L-06R at Toronto Pearson International Airport at 20:01 UTC...

; Tuninter Flight 1153
Tuninter Flight 1153
Tuninter Flight 1153 was a Tuninter Airlines flight from Bari International Airport in Bari, Italy, to Djerba-Zarzis Airport in Djerba, Tunisia. On 6 August 2005, the Tuninter ATR-72 ditched into the Mediterranean Sea about 18 miles from the city of Palermo. Sixteen of the 39 people on board died...

 (an ATR-72 crash in the Mediterranean Sea
Mediterranean Sea
The Mediterranean Sea is a sea connected to the Atlantic Ocean surrounded by the Mediterranean region and almost completely enclosed by land: on the north by Anatolia and Europe, on the south by North Africa, and on the east by the Levant...

); Helios Airways Flight 522
Helios Airways Flight 522
Helios Airways Flight 522 was a Helios Airways Boeing 737-300 flight that crashed into a mountain on 14 August 2005 at 12:04 EEST, north of Marathon and Varnavas, Greece. Rescue teams located wreckage near the community of Grammatiko from Athens...

 crash, killing 121 in Greece; West Caribbean Airways Flight 708
West Caribbean Airways Flight 708
West Caribbean Airways Flight 708 was a West Caribbean Airways charter flight which crashed in a mountainous region in northwest Venezuela on the morning of Tuesday, 16 August 2005, killing all 152 passengers and eight crew....

's crash in Venezuela
Venezuela
Venezuela , officially called the Bolivarian Republic of Venezuela , is a tropical country on the northern coast of South America. It borders Colombia to the west, Guyana to the east, and Brazil to the south...

, killing 160; and TANS Peru Flight 204
TANS Peru Flight 204
TANS Perú Flight 204 refers to a domestic scheduled Lima–Pucallpa–Iquitos passenger service, operated with a Boeing 737-244 Advanced, that crashed on approach to Pucallpa Airport on , killing 40 of 98 occupants aboard.-Aircraft:...

, killing 41 out of 100 people on board when it crashed in Peru
Peru
Peru , officially the Republic of Peru , is a country in western South America. It is bordered on the north by Ecuador and Colombia, on the east by Brazil, on the southeast by Bolivia, on the south by Chile, and on the west by the Pacific Ocean....

.

Flight 091 has the second highest death toll of any aviation accident in Indonesia after Garuda Indonesia Flight 152
Garuda Indonesia Flight 152
Garuda Indonesia Flight 152 was a scheduled domestic Indonesian passenger flight from Jakarta to Medan Sumatra operated by state owned flag carrier Garuda Indonesia. On September 26, 1997, the Airbus A300 flying this route, registered PK-GAI, crashed into woodlands 29 km from Medan in low...

 and the highest death toll of any accident involving a Boeing 737-200 ever.

Survivors

A passenger named Rohadi Sitepu told Metro TV from hospital that he and five other people seated in the back of the plane in Row 20 had all survived. "There was the sound of an explosion in the front and there was fire and then the aircraft fell," he said. Rohadi said he escaped the blazing wreck by jumping through the torn fuselage and fleeing on foot as four large explosions erupted behind him.

Another survivor, Freddy Ismail, told Elshinta Radio from his hospital bed that the aircraft seemed to be experiencing mechanical difficulties after take-off. "After take-off, the noise of the engine suddenly became very loud and the aircraft began shaking intensely before it suddenly fell," he said.

Nationalities of the passengers and crew

Note: This doesn't include the thirty-nine casualties on ground.
Nationality Passengers Crew Total
Total Killed Total Killed Total Killed
114 98 5 5 119 103
1 1 0 0 1 1
Total 115 99 5 5 120 104

Aircraft and airline

The aircraft, registration PK-RIM, was built in 1981 and formerly belonged to Lufthansa
Lufthansa
Deutsche Lufthansa AG is the flag carrier of Germany and the largest airline in Europe in terms of overall passengers carried. The name of the company is derived from Luft , and Hansa .The airline is the world's fourth-largest airline in terms of overall passengers carried, operating...

 where it was registered as D-ABHK "Bayreuth". The aircraft had passed extensive safety tests in June and should have been airworthy until at least 2013.

Mandala Airlines was established in 1969 and is one of several low-cost airlines that serve the vast Indonesian archipelago. At the time of the accident it was 90-percent owned by a foundation set up by the Indonesian Army
Indonesian Army
The Indonesian Army , the land component of the Indonesian Armed Forces, has an estimated strength of 328,517 regular personnel. The force's history began in 1945 when the Tentara Keamanan Rakyat "Civil Security Forces" served as paramilitary and police.Since the nation's independence struggle,...

 strategic reserve Kostrad
Kostrad
Kostrad is the Indonesian Army's Strategic Reserve Command. Kostrad is a Corps level command which has up to 35,000 troops...

 (Komando Strategis Angkatan Darat). In 2006 it was acquired by Cardig International and Indigo Partners. It has 1,000 employees (at March 2007).[1]

Preliminary indications

Witness statements were contradictory, with some claiming that the plane rose to an altitude of 90 metres before appearing to shake (possibly indicating a stall
Stall (flight)
In fluid dynamics, a stall is a reduction in the lift coefficient generated by a foil as angle of attack increases. This occurs when the critical angle of attack of the foil is exceeded...

) and veer to the left, while others said that the aircraft failed even to clear the landing lights (not ILS antenna
Instrument Landing System
An instrument landing system is a ground-based instrument approach system that provides precision guidance to an aircraft approaching and landing on a runway, using a combination of radio signals and, in many cases, high-intensity lighting arrays to enable a safe landing during instrument...

 as mentioned in many media) at the end of the runway before veering to the right and crashing immediately.

It had been suggested that illegal overloading could be responsible for the aircraft's apparent inability to climb, but confirming this would be almost impossible given the intense fire produced and the presence of large amounts of debris from the houses which were destroyed; however, observers reported smelling durian
Durian
The durian is the fruit of several tree species belonging to the genus Durio and the Malvaceae family . Widely known and revered in southeast Asia as the "king of fruits", the durian is distinctive for its large size, unique odour, and formidable thorn-covered husk...

 fruit in the crash .http://www.suaramerdeka.com/harian/0509/11/nas02.htm. It had been widely reported that the overloading was due to 2 or 3 tonnes of durian
Durian
The durian is the fruit of several tree species belonging to the genus Durio and the Malvaceae family . Widely known and revered in southeast Asia as the "king of fruits", the durian is distinctive for its large size, unique odour, and formidable thorn-covered husk...

 fruit brought by the Sumatran governor and former governor travelling on the flight intended as gifts to bring to Jakarta, and not listed on the flight's load manifest http://simpilot.net:8080/cgi-bin/WebX?14@625.pmkNaY3KkdE.36@.3d767dad/17!skip=-1. The reports claimed that the governors had already been refused travel on Garuda
Garuda Indonesia
PT Garuda Indonesia Tbk , publicly known as Garuda Indonesia, is the flag carrier of Indonesia. It is named after the mystical giant bird Garuda of Hinduism and Buddhist mythology. It is headquartered at Soekarno-Hatta International Airport in Tangerang, near Jakarta, the capital city of Indonesia...

, the national airline, because of the excess weight of the highly prized fruit, which were then in season in Sumatra. A preliminary probe into the crash had found a fuel problem with one of the plane's engines. Other causes, including engine failure and pilot error, were also under investigation. The black box flight recorders
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...

 were recovered and sent to the US for analysis.

Official investigation

The official final report on the accident was released by the National Transportation Safety Committee
National Transportation Safety Committee
The National Transportation Safety Committee is an Indonesian government agency charged with the investigation of air, land, rail, and marine transportation safety deficiencies. It has its headquarters in Jakarta....

 (NTSC) of Indonesia on 1 January 2009. According to it the probable causes of the accident were the following:
  • The aircraft took-off with improper take off configuration namely with retracted flaps
    Flap (aircraft)
    Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...

     and slats
    Leading edge slats
    Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...

     causing the aircraft failed (sic) to lift off.
  • Improper checklist
    Checklist
    A checklist is a type of informational job aid used to reduce failure by compensating for potential limits of human memory and attention. It helps to ensure consistency and completeness in carrying out a task...

     procedure execution had led to failure to identify the flap in retract position.
  • The aircraft’s take off warning horn was not heard on the CAM channel of the CVR
    Cockpit voice recorder
    A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...

    . It is possible that the take-off configuration warning horn was not sounding.

Similar incidents

Other accidents where the aircraft crashed shortly after takeoff, due to improper settings of flaps/slats, with parallel failure of the takeoff misconfiguration warning horn system:
  • Delta Air Lines Flight 1141
    Delta Air Lines Flight 1141
    Delta Air Lines Flight 1141 was a routine domestic passenger flight between Dallas-Fort Worth International Airport and Salt Lake City International Airport, Salt Lake City, Utah...

  • Spanair Flight 5022
    Spanair Flight 5022
    Spanair Flight JK 5022, from Barajas Airport in Madrid to Gran Canaria Airport in Gran Canaria, Spain, crashed just after take off from runway 36L of Barajas Airport at 14:24 CEST on 20 August 2008. The aircraft was a McDonnell Douglas MD-82, registration EC-HFP...

  • Northwest Airlines Flight 255
    Northwest Airlines Flight 255
    Northwest Airlines Flight 255 was a flight that originated at MBS International Airport in Saginaw, Michigan, and was scheduled to terminate at John Wayne Airport in Orange County, California, with intermediate stops at Detroit Metropolitan Wayne County Airport in Romulus, Michigan, near Detroit,...

  • Lufthansa Flight 540
    Lufthansa Flight 540
    Lufthansa Flight 540 was a scheduled commercial flight for Lufthansa operated with a Boeing 747-130, carrying 157 people . The flight was operating the final segment of its Frankfurt–Nairobi–Johannesburg route. On 20 November 1974 it crashed and caught fire shortly past the runway on...


Sources



External links

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