reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2011 MA60 LoC in G-A Kaimana Indonesia

Brief account : 

The twin turboporop was intending to make a visual approach when conditions deteriorated. Control was lost shortly after an attempted transition to a go around due to lack of sufficient visual reference. The aircraft was destroyed on impact with the sea surface 800 metres south west of the runway threshold at a high rate of descent and all 25 occupants were killed. 

Crew-related factors : 

The Captain was highly experienced in the airline (34 years, 24,500 hrs) but had very low time on type (199 hrs). The F/O was extremely inexperienced, with only 370 hrs total of which 234 were on type.  The investigators noted the "....interaction between the PIC and the SIC suggested a steep trans-cockpit authority gradient in which the SIC may not challenge the decisions and actions of the PIC." 

The airport had no published instrument approach procedure so the plan was to make a visual approach. The F/O was designated as PF initially.  No briefing was carried out, and the Captain gave detailed instructions to the F/O on how to conduct the flight with the autopilot engaged, while seeking unsuccessfully to obtain visual reference in conditions which had deteriorated below the required visual criteria (2km in rain vs 5 km).  The autopilot was disengaged just below 1000ft. 

About 13 seconds later the Captain took control at 650 ft.    An automated "minimums" call was heard (although no IFR approach was published, it appears a DH had been set).  Shortly after the Captain asked several times if the F/O could see the runway. The F/O could not, and shortly after the Captain initiated a go-around while in a fairly steep left turn.

The Captain may have reverted to procedures appropriate to his former type as incorrect calls for flap retraction were made. The pilots had also received different training on this procedure.    

Type: 
MA60
Where: 
Kaimana Indonesia
Expected weather: 
Visual
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
Below DH/A
Damage: 
Serious
PicMA potential: 
Major
Year: 
2011
Time: 
Day
Deterioration: 
Yes
Vert Guidance: 
None
Both Head Up: 
Yes
LoC: 
Yes
Operator: 
Merpati
Fully prepared: 
No
Actual Weather: 
Rain
Autopilot : 
Y
CCAG: 
High