Aviastar crash report blames pilot error

The final report on the crash of Aviastar Mandiri’s BAe 146-300 PK-BRD (msn E3189) concludes that “[t]he crew did not appear to have awareness of the aircraft’s proximity with terrain until impact with terrain was imminent” and that it “did not act on the Enhanced Ground Proximity Warning System aural warnings, and did not conform to the operator’s published operating procedures”. The 146 crashed onto a mountain near Wamena, in Papua Indonesia, on 9 April 2009, while going around after a balked landing. The crew apparently failed to react to nine aural alerts from the 146’s EGPWS during the downwind leg, and another nine on the base leg. After the first officer expressed increasing concern over nearby terrain, the captain banked the aircraft steeply, with the bank angle reaching 49 degrees. The 146 hit Pikei Hill on Tengah Mountain, about 3.5nm northwest of the airport. The aircraft was destroyed, and all six crewmembers on board were killed. The investigation determined that there were no defects on the 146 prior to impact, and that the EGPWS was functioning properly. The report blamed the crew’s failure to react properly to EGPWS warnings in part to their lack of training in its proper use.

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