MODUS-MODUS KEGAGALAN

PESAWAT UDARA
BACKGROUND

BOEING 737 “ALOHA” ACCIDENT ( April 28, 1988 )

Aloha flight
243 B-737-200
(28/04/1988)

19 years old;
89.680 FC;
35.496 FH
Root cause : fatigue
corrosion at upper
fuselage
The aircraft lost 1/3 of its roof due to a stress fracture while cruising
at 24,000 feet. One Flight Attendant was sucked from the airplane,
which subsequently made a safe emergency landing.
BACKGROUND

BOEING 737 “ALOHA” ACCIDENT ( April 28, 1988 )

1 2

4 3
BACKGROUND
BOEING 737 “ALOHA” ACCIDENT ( April 28, 1988 )
Response to Aloha accident
 June 1988 FAA hosted “The International Conference on
Aging Airplanes” resulted :
• Organizations of operators, manufacturers and
regulators (AAWG = Airworthiness Assurance
Working Group) to investigate and propose solutions
to the problems evidenced as a result of the accident
• The major topics are :
– Review of the existing Service Bulletins (SB),
Supplemental Inspection Documents and
Maintenance Program
– Establishment of a Corrosion Prevention and
Control Program (CPCP)
– Widespread Fatigue Damage evaluation
– Assessment of repair
BACKGROUND
B747-100 “TWA” ACCIDENT (July 17, 1996)

TWA flight 800

B747-100
(17/07/1996)

25 years old;
18.000FC;
Root cause : 90.000FH
wiring deterioration on Wing
centre lead to Fuel Tank
explosion

The aircraft impacted the water in the Atlantic Ocean near

New York after 11 minutes take off (13,700ft sea level) due
to explosion of the centre wing fuel tank, killed 230
passenger and crew on-board
BACKGROUND

B747-100 “TWA” ACCIDENT (July 17, 1996)

Response to TWA Accident

White House Commission on Aviation

Safety and Security requested FAA to
include Non-structural Aging Program
into the existing Aging Program
Research (August 22, 1996)
BACKGROUND
MD-11 “SWISSAIR” ACCIDENT ( September 02, 1998 )

Root cause :
Swissair flight 111
faulty (arcing) wiring in the
MD-11
cockpit ignited flammable
(02/09/1998)
covering and insulation blanket
and then cause fire in the cockpit 7 years old;
36.041FH

The aircraft was approximately one hour into a flight from New York to
Geneva when the crew reported smoke in the cockpit. While attempting an
emergency landing in Halifax, Nova Scotia, the aircraft crashed into the
Atlantic Ocean. Possible ignition of the aircraft's insulation which led to a
fire and loss of control and killed 229 passenger and crew
BACKGROUND

MD-11 “SWISSAIR” ACCIDENT ( September 02, 1998 )

Arcing
Wire
Source

Melted copper on Wire

BACKGROUND
MD-11 “SWISSAIR” ACCIDENT ( September 02, 1998 )

Response to Swissair flight 111 Accident

The Boeing Company issued a Flight

Operations Bulletin (No. MD-11-99-04),
which states: "Boeing advises that any time
smoke has been detected and the source
cannot be POSITIVELY identified and
eliminated, the aircraft should be landed as
soon as possible"
BACKGROUND
CN235 “Ventral Door Separation“ (January 02, 2000)

Hook & Port Fitting

Ventral Door
Baggage Compartment

When flying a post maintenance test flight at altitude 16,000ft, speed 150kts,
heading of 100 on radial 100 about 15nm from Husein Sastranegara Bandung
Airport, its Ventral Door detached and separated from the aircraft
BACKGROUND
CN235 “Ventral Door Separation“ (January 02, 2000)

SEM photo

Hook & Port Fitting

‘Mud Crack’
pattern
BACKGROUND
CN235 “Ventral Door Separation“ (January 02, 2000)

Response to CN235 Ventral Door Accident

 On January 28, 2000 PT. IPTN issued Service Letter No. 00-
53-01 (Inspection of Guide Hooks and Hinge Assembly of
Ventral Door and Rear Fuselage Port Fitting)

 DGAC issued Airworthiness Directive No. 00-01-019 to

conduct special inspection on all CN235 aircrafts in
accordance with PT. IPTN Service Letter No. 00-53-01

 Service Bulletin (SB) No. N235-52-230 (Guide Hooks assy and

Hinge Assy of Ventral Door and Port Fitting Assy of Rear
Fuselage Inspection) issued by PT. IPTN on April 28, 2000
BACKGROUND
PUMA SA330 ACCIDENT (December 25, 2000)

Tail Rotor Pitch Link

On December 25, 2000 at 10.00 WIB, Helicopter PUMA HT-3305 at Kaybar,
Manokwari, East Indonesia, starting by abnormal vibration at altitude 7500 ft,
then the aircraft went down for landing. At altitude about 15-20 ft the pilot
pushed pedal for landing and not long after that the pylon was broken and fell
to the ground, meanwhile the aircraft turned uncontrolled three times before
fell to the ground and injured all 7 crew
BACKGROUND
PUMA SA330 ACCIDENT (December 25, 2000)
BACKGROUND
PUMA SA330 ACCIDENT (December 25, 2000)

Recommendation to AS330 PUMA Accident

 Before flight it is necessary to check the play of
spherical bearing of pitch link
 If it is found play on the bearing, check the actual length
of the pitch link compared to the allowable limit /
dimension toleranc
 It is also necessary to check crack on the pitch link
(especially on the shank), if it is found crack, the part
shall be directly replaced by the new one
 On the flight whenever pilot detect an abnormal
vibration, it is suggested to find place for running
landing without additional power
BACKGROUND

B747-200 “CHINA AIRLINES” ACCIDENT ( MAY 25, 2002 )

China Airlines Flight 611 flew apart and plunged into the ocean about 50
kilometers, or 30 miles, off the coast on May 25, 2002, just as it reached
cruising altitude after taking off from Taipei en-route to Hong Kong, killed all
225 passenger and crew. This 22 years old aircraft has 21,398fc and 64,810fh.
Root cause : initial damage on tail section since 1980 then growing to be fatigue
crack and did not repair properly according to manual
BACKGROUND
B747-200 “CHINA AIRLINES” ACCIDENT ( MAY 25, 2002 )
Response to CI611 Accident
ASC (Aviation Safety Council of Taiwan, China) recommended China
Airlines such the followings :
– Perform structural repairs and damage assessment according to SRM
or other approved regulation
– Review the record keeping system to ensure that all maintenance
activities have been properly recorded
– Access and implement safety related-airworthiness requirements
– Conduct CPCP in accordance with the approved maintenance
documents
– Enhance maintenance crews‟ awareness with regard to the irregular
shape of the aircraft structure that may indicate hidden structural
damage
– Reassess the relationship with the aircraft manufacturer
– Ensure that all safety-related service documentation is received and
assessed
– Consider reviewing the inspection procedure for maintenance
records
– Ensure that the implementation of continuing airworthiness
includes safety aspects, operational factors and uncertainty factors
in workmanship and inspection
 Garuda Indonesia
GA421
Boeing 737-300
PK-GWA
Bengawan Solo River,
Central Java
16 January 2002
1 Orang Tewas
 Root cause :
- Entered in to heavy
rain than Engine
Flame out
- Loss electrical power
 PT. LION AIR
MacDonnell Douglass MD – 82
PK-LMN
Adi Sumarmo Airport, Solo
30 November 2002
25 Orang Tewas
 PT. DIRGANTARA AIR SERVICE
CASA NC 212-100; PK-VSN
Muaratewe,Palangkaraya Kalimantan
Tengah
26 Maret 2005
 CN235-100 M
Loksaumawe Aceh,
Sumatra Utara
21 Juli 2005
5 Orang Tewas

Root cause :
- Psychologies effect
- Sudut datang terlalu tinggi
- terrain slope curam
PT. MERPATI NUSANTARA
CASA NC 212-200; PK-NCL
Bandaneira, Banda
05 Juni 2006
 PT. MERPATI
NUSANTARA
NC 212-200;
PK-NCL
Bandaneira, Banda
05 Juni 2006
Tidak ada korban
tewas
 Root cause :
- Psychologies effect
- Environment condition
[Obstacle & Weather]
- Pilot Seat Retreat
- Over due recover
 PUSPENERBAD
CASA NC 212-200;
A-9032
Ahmad Yani Airport Semarang
19 Juli 2006
2 Orang Tewas
CASA NC 212-200;
Ahmad Yani Airport Root cause :
Semarang - Maintenance
19 Juli 2006 - Link Arm
- Mutual
2 Orang Tewas - Un-proper action
 AVIASTAR
CASA NC 212-200;
PK-BRM
Tanjung Bara, Kalimantan Timur
7 Februari 2007
 PUMA
SA330
ACCIDENT
(December
25, 2000)
 AS-202 Bravo
Dislitbangau, September 2013)
BLACK BOX: tadinya warna orange,
menjadi black terkena api

33
CVR tape dalam cangkang anti api
& ultra high G’s

34
Kenapa gagal T/O?
Slats & Flaps retracted,
Lift kurang

35
Thrust Reverser deployed…. Benarkah?

36
Gear Box Shaft: torsional deformation & patah
Saat impact, engine masih ada power

37
Linkage pada Nose L/G: patah fatigue?

38
Perm. Patahan: Beach marks (dari seb. kanan)
Ciri fatigue fracture

39
SEM: fatigue striations,
perambatan retak per siklus tegangan

40
Awal retak dari sisi depan linkage. Kenapa?
Kemungkinan dari “dent” akibat diketok.

41
Permukaan patah: Fatigue di bag. atas

42
Awal fatigue di “bawah” lapisan hard Cr

43
Torque link: patah akibat shimmy

44
Permukaan patah: low cycle fatigue
berawal dari sebelah bawah,
akibat tegangan sangat tinggi

45
High temp. fatigue pada turbine disc akibat
adanya residual stress dari goresan sebelumnya.
Retak fatigue berawal dari O menjalar ke luar dan dalam.

46
Tail rotor shaft bearing support:
seb.kanan diambil dari dasar laut

47
Bearing support patah (di sisi kiri). Kenapa?

48
3mm too long bolt !!!!

49
Bolt yang terlalu panjang:
Terjadi bottoming: tidak ada clamp-force

50
 Urutan peristiwa

• Pada satu sisi (yang bolt-nya terlalu panjang) bearing support tidak ada
clamping force

• Sisi lain (yg bolt-nya benar) mengalami “overload” hingga bolt segera patah
fatigue

• Bearing tidak lagi ter-support

• Tail rotor shaft bergetar hebat dan patah

• Helikopter mengalami yawing tidak terkendali dan crash.

51
Bekas api menyembur (pada combustors):
in-flight fire

52
Pig-tail patah dan molten: sumber api

53
Scratch line / gouging pada lube-oil pump,
Terjadi internal leak, low oil quantity,
One engine shut down

54
Metallic chips on a filter
Asal keausan dapat dilacak

55
Bulb analysis thd lampu instrumen
Utk melacak status instr. / sistem saat impact

56
Saat impact lampu menyala, filament lembek,
spiral filament berdeformasi

57
Filament utuh: tidak menyala saat impact

58
 Apakah
modus-modus
kecelakaan
pesawat
udara?
Data Statistical kecelakaan pesawat udara
Data Statistical penyebab kecelakaan pesawat udara

Note: Non dimensional

ACCIDENT CAUSES by 80% human and 20% others

Mengapa Incident / Accident Terjadi ?

 Rantai Penyebab Kecelakaan

(Chain of Event)
 ACCIDENTS

INCIDENTS

Investigation

ERRORS
(UNREPORTED
OCCURRENCES)
TUJUAN MENGETAHUI MODUS-MODUS
KEGAGALAN PESAWAT UDARA
• Mengetahui penyebab kejadian
[Root cause / chain of even]

• Rekomendasi
[Mencegah kejadian serupa
terulang]

Tidak ditujukan untuk menyalahkan/ pertanggungjawaban

seseorang atau Institusi
 RESPONSIBILITIES OF
INVESTIGATION

Investigation in any civil or Civil & Mil accident in Indonesia

territory is responsibility of Government investigator.

Civil Military

Department of Air Transport Department of Defense ???

Dislambangjaau
TNI - AU
Komite Nasional
Keselamatan Transportasi
[KNKT] Penyelidikan Pada Kecelakaan
Pesawat Udara [PPKPU]
TNI - AU
 NOTIFICATION OF ACCIDENT

• AC Type, Model, Nationality &

Registration
• PIC name, Date & Time
• Departure & Intended Arrival
aerodrome
• Geographical position & Lat/long
• No of Crew & Pax killed & injured
• No of others Killed & Injured
• Nature of accident
• Proposed of delegation
• Physical characteristic of Accident
area
 INVESTIGATION
• CREW, PAX, etc [if alive] DATA
• STRUCTURE, ENGINE &
SYSTEM
• COCKPIT / switches
(procedures)
• RECORDERS: FDR, CVR
• Witness , Pictures, video,
Wreckage, etc
• Public hearing (invite
public)
• Supporting data: SDR /
FMD reports, SB’s, AD’s,
MLB, FC/B/COM, AFM,
MM, QRH, etc
 INVESTIGATION
TECHNIQUE
• QUALITATIVE &
QUANTITATIVE
• CAUSE & EFFECTS
• CHAIN OF EVENTS (Top -
Bottom & Vice Versa)
• MODELING & SIMULATION
FOR TRAJECTORY ANALYSIS
• COMPUTER SIMULATION
• RECONSTRUCTION
• FME (FAILURE MODES &
EFFECTS)
• FT (FAULT TREE ANALYSIS)
 ON-SITE ACTIONS

• Initial On Site Action

• Accident Diagrams

• Accident Photography
• Fire Investigation
• Structural Investigation
• Aircraft Systems
• Instrument Investigation
• Aircraft Records
• Witness Interviewing
 REPORTING

Title.
The Final Report begins with a title comprising:
- Name of the operator;
- Manufacturer,
- Model,
- Nationality and registration marks of the aircraft;
- Place and date of the accident or incident.
Synopsis.
Following the title is a synopsis describing briefly all relevant
information regarding:
- Notification of accident to national and foreign authorities;
-Identification of the accident investigation authority and
accredited representation;
- organization of the investigation;
- authority releasing the report and date of publication; and
- concluding with a brief résumé of the circumstances leading to
the accident.
 REPORTING

Body.
The body of the Final Report comprises the following main headings:
1. Factual information
2. Analysis
3. Conclusions
4. Safety recommendations

Appendices.
 Accident.

An occurrence associated with the operation of an aircraft - which

takes place between the time any person boards the aircraft with
the intention of flight until such time as all such persons have
disembarked, in which:
a) a person is fatally or seriously injured as a result of :
- being in or upon the aircraft, or
- by direct contact with the aircraft or
- anything attached thereto; or

b) the aircraft incurs damage or structural failure which:

- adversely affects the structure strength, performance or flight
characteristics of the aircraft and
- would normally require major repair orreplacement of the
affected component;

c) the aircraft is missing or is completely inaccessible.

Investigation.
A process conducted for the purpose of accident
prevention which includes the gathering and
analysis of information, the drawing of
conclusions, including the determination of
cause(s) and, when appropriate, the making of
safety recommendations

Investigator-in-Charge.
The person charged with the responsibility for
the organization, conduct and control of an
investigation
 ACCIDENT DIAGRAMS
Wreckage Diagramming
Typical items include in an accident
diagram include:
• Location references (roads,
buildings, runways, etc.)
• Direction and scale reference
• Elevations / contours (depending
on the level of detail)
• Impact heading / scars
• Location of human remains
• Location of major aircraft parts
• Burn areas
• Damage to buildings, structures,
trees, etc.
• Location of eye witnesses
 ACCIDENT PHOTOGRAPHY

Photography of aircraft accidents is used for

two main purposes.
1. Photography as evidence in recording
medium
2. Photography as a memory aid

When taking photographs, investigators should

first answer the following questions:
• What am I trying to accomplish?
• Who is going to see the picture / video
• Should I take back up photo’s with other
media?
• How should I incorporate photos / videos
into my report?
ACCIDENT PHOTOGRAPHY
ACCIDENT PHOTOGRAPHY
 INVESTIGASI ‘FIRE’

NC212-200
PK-VSE
Accident
(January
2008)
 INVESTIGASI ‘STRUCTURE’

CN235-100 A2301 TNI-AU

ACCIDENT (July, 2005)

Patah Statik, mengkilat &

bersudut (ductile fracture)
 INVESTIGASI ‘SYSTEM’

PUMA
SA330
ACCIDENT
(December
25, 2000)
 INVESTIGASI ‘ENGINES’

CN235-100 A2301 TNI-AU ACCIDENT

(July, 2005) View V
 INVESTIGASI ‘PROPELLERS’

NC212-200 PK-VSE
Accident (January 2008)

Propeller Kanan Un-feather

dan Tidak Berputar

FD
Bentuk ‘bent’ tidak sesuai dengan
putaran, kemungkinan tertimpa sesuatu

Propeller Kiri Un-feather dan

Kemungkinan Berputar
FD
 INVESTIGASI ‘INSTRUMENTS’

Altimeter Vertical Speed

Engine Torque and RPM
 INVESTIGASI ‘INSTRUMENTS’

Fuel Level Left Fuel Level Righ SRL & Start CMPTR Battery Temp No
Generator Left Generator Right Pitot Heat Left Pitot Heat Right Inverter No 1 Unsafe Door
Tank Tank Right 1

                   

Oil Pressure Left Fuel Shutoff Right Fuel Shutoff Windshield Heat Windshield Heat SRL & Start CMPTR Battery Over
Oil Pressure Left Inverter No 2 Over speed
Right Valve Valve Left Right Left Temp

                   

Chip Detector Chip Detector Fuel Pressure Fuel Pressure Air Intake Heat Air Intake Heat Baggage Compt. Battery Temp No Battery Temp No
Aux Inverter
Left Right Left Engine Right Engine Left Right Smoke 2 3

                   
 INVESTIGASI ‘INSTRUMENTS’

Light Bulb
Investigation Filamen Pasca
Impak
(Lampu Mati)

Filamen Normal

Filamen Pasca Impak

(Lampu Menyala)
 FACTORS AFFECTING WITNESS
REPORTING

A witness interview can be affected by several

factors including:
• Witness background in aviation/ IQ
• Perception of the witness
• Emotion / excitements
• Interpretation of the ambiguous
• Agreement with other witnesses

Other reasons for inaccurate statements

• Environmental
• Psychological
 ANALYSIS

Analyze, as appropriate, only the information

documented in Factual information and which is
relevant to the determination of conclusions and
causes.
 CONCLUSIONS

List the findings and causes established in

the investigation.

The list of causes should include both the

immediate and the deeper systemic causes.
 SAFETY RECOMMENDATIONS

As appropriate, briefly state any

recommendations made for the purpose
of accident prevention and any resultant
corrective action
DEFINITION
AGING
AIRCRAFT

AIRFRAME/ NON STRUCTURE/

STRUCTURE AIRCRAFT SYSTEM

DEGRADATION
COROSSION FATIGUE CONTAMINATION OBSOLETE
PERFORMANCE

WEAR VIBRATION MOISTURE

AGING AIRCRAFT Classification & Sources

Note : Sources may also be occurred as a combination of each sources
DEFINITION

“Aging Aircraft” (Structure) is :

“aircraft which have exceeded their certified
airframe design life”
Source : „ATSB Transport Safety Report B20050205, February 2007”

 Airframe design life : is the period of time (in flight

cycles/hours) established at design and/or certification during
which the principal structure will be reasonably free from
significant cracking including widespread fatigue damage

 In general, airframe design goal life is about 60,000 flight cycle

or approximately similar with 20 years calendar

Aging Aircraft [Structure] well established

DEFINITION
“Aging Aircraft” (Non-Structure) is :
“aircraft which have exceeded their non-structure
(electric wire) design service objective life”
 Wire, it seems, may not last as long as the 20 or 30-year design
service objective of the airplane (DSO). (Air Safety Week,
September 27, 1999)
 There appears to be a near linear relationship between aircraft
(structure) age and the degradation of wiring due to chafing (Mark
Brown, GRC International, Air Safety Week, September 27, 1999)
 For wire, service life is influenced by a variety of factors:
* As temperature increases, age decreases.
* As humidity increases, age decreases.
* Vibration accelerates aging.
* Poor installation can accelerate aging

Aging Aircraft [Non Structure] under development

by FAA, NASA, Aircraft Manufacturer and others
science & research institutes
DEFINITION
AIRCRAFT AGE
– Aircraft Age will depend on :
 Calendar year
 Flight Cycles
 Flight Hours
– Design Goal of the Aircraft :
 NC212 : 20 yrs or 40,000 FC
 CN235 : 20 yrs; 60,000 FC; 50,000 FH
 B707 : 20 yrs; 20,000 FC; 60,000 FH
 B727 : 20 yrs; 60,000 FC; 50,000 FH
 B737 : 20 yrs; 75,000 FC; 51,000 FH
 B747 : 20 yrs; 20,000 FC; 60,000 FH
 DC8 : 20 yrs; 25,000 FC; 50,000 FH
 DC9 : 20 yrs; 40,000 FC; 30,000 FH
 DC10 : 20 yrs; 42,000 FC; 60,000 FH
Source :
IAe &
http://www.boeing.com/commercial/aeromagazine/aero_02/textonly/
textonly.html
DESCRIPTION OF FAILURE

AGING AIRCRAFT
FACTOR

OPERATIONAL MAINTENANCE

Un-proper
maintenance
HOURS/
CLIMATE LOAD GEOGRAPHICS
CYCLES

FACTOR(S) ACCELERATING AGING AIRCRAFT

Note : Aging may also be occurred as a combination of each factor
DESCRIPTION OF
AGING AIRCRAFT

• Aging mechanism sources :

– Fatigue  thru repetitive cyclic loading
– Corrosion
– Wear
 thru time
– Deterioration
 DESCRIPTION OF
FATIQUE

Fatigue Failure
Occurs due to cyclic loading
 The mechanism of failure is the
initiation and propagation of cracks
 Final fast fracture will occur by either
Brittle or Ductile fracture

Macroscopic Appearance :
 The surface is covered with a
relatively flat, smooth region where
fatigue crack growth took place, and
a rougher, fast fracture region

Microscopic Appearance :
 Ductile in appearance (no
cleavage) but not suficient to create
dimples as in ductile failure Beach Mark

Striation
 Fatigue Failure
(FRACTURE REGION)

Fast Fracture Region

Fatigue Region

Corrosion of Fatigue Surface

Especially Near Origin

Beach Marks
Origin of Fatigue Crack “Clam shell” Marks
DESCRIPTION

FATIGUE MECHANISM

FATIGUE DIAGRAM
DESCRIPTION

Multiple Side
Damage

Multiple Element
Damage
DESCRIPTION

CORROSION
FAILURE
Definition :
 Destructive attack of metals by reaction
with the environment
 Need condition which allow electron to
flow
 Moist or electrolyte must be present General/Uniform Corrosion

Two Fundamental Types :

 General/Uniform Corrosion
 Localized Corrosion,
 Galvanic Corrosion
 Crevice Corrosion
 Pitting Corrosion
 Intergranular Corrosion
 Stress Corrosion
 Exfoliation Corrosion Fatigue
 Corrosion Fatigue
DESCRIPTION

Wear
Failure
Causes loss material from the surface
as a result of rubbing contact with
another surface
 May cause direct failure, or
 Contribute to other type of failure
such as fatigue
 CIVIL AVIATION SAFETY
-22 NOV 2004 SUDDEN DEATH IN FLIGHT
SPD-PONTIANAK PK GCC-GA 500
-25 JULI 2006 SUDDEN DEATH IN FLIGHT
DPS BALI PK GPE GA 722
- 5 SEPT 2006 SUDDEN DEATH IN FLIGHT
SOETA JKT PK CJM – SJY 210
-17 NOV 2006 PUNCAK JAYA IND TRIGANA AIR
SERVICE TWIN OTTER 300 PK YPY 12/12
- 1 JAN 2007 PARE-PARE ADAM AIR BOEING
737 4Q8 PK-KKW 102/102
- 7 MARET 2007 JOGYA IND GIA BOEING 737
497 PK GZC 22/140
- 28 JAN 2008 NEAR MALINAU IND DAS CASSA
NC 212 – 200 PK USE 3/3
-- 30 JAN 2008 TWIN OTTER AVIA STAR
JAYAPURA
-- 6 MARET 2008 TRANSALL C -160
MANUNGGAL AIR WAMENA PAPUA
-- 12 MARET 2008 ADAM AIR HANG NADIM
BATAM
-16 JAN 2009 MERPATI BOEING 737-400
MZ 762 GAGAL TINGGAL LANDAS AKIBAT
PECAH BAN DI MAKASAR
-20 FEB 2009 TWIN OTTER TRIGANA
TERGELINCIR BAN DEPAN PATAH DI BIOGA
JAYAWIJAYA
-23 FEB 2009 MD 90 LION AIR JT 972
EMERGENCY LANDING AK BAN DEPAN
TIDAK KELUAR DI HANG NADIM BATAM
-27 FEB 2009 BATAVIA AIR B 737-300
KESASAR KE KETAPANG TUJUAN
PONTIANAK
-9 MARET 2009 LION AIR MD-90 PK LIL
TERGELINCIR KELUAR LANDASAN DI
CENGKARENG – SOETA
-8 APRIL 2009 AVIASTAR BAE TABRAK
GUNUNG DI PAPUA WAMENA
-17 APRIL 2009 MIMIKA AIR 6 PK-LTJ
PUNCAK JAYA PAPUA
- 30 APRIL 2009 PSWT STIP CURUG
BEECH RAY THEON C23 PK ANW JATUH
DI TENJO
 AIRCRAFT INCIDENT AND ACCIDENT
OF IAF DURING 2004 – 2006 *
-23-12-04 HELIKOPTER SUPER PUMA WONOSOBO
(SUB THRESHOLD ILUSION)
-- 8-02-05 BRAVO LM 2030 LANUD ADI
-20-07-05 OV 10 TABRAK GUNUNG DI MALANG
(GRAVEYARD SPIRAL ILLUSION)
-21-07-05 CN 235 DI LHOKSEUMAWE ACEH
(SOMATOGRAVIC ILLUSION)
-- 12-10-05 H3451 S-58 T TWIN PACK DI PAPUA
-16-3-06 : LD 3004 MENYENGGOL ELEVATOR LD 3409 PADA WAKTU
LINE UP POSITION TERBANG MALAM
(NIGHT VISION/DEPTH PERCEPTION)
-- 6-9-06 : A-2303 LANDING DGN SINGLE ENGINE
-21-11-06: TT 0207 HAWK 200 LOST POWER-OVER SHOOT -> EJECT

WHAT ELSE OF THE EFFORT THAT CAN WE DO TO DECREASE

THE INCIDENT AND ACCIDENT RATE ?
* QUOTED FROM THE ROAD TO ZERO ACCIDENT 2006;
DISLAMBANGJA AU
 Tempat & Waktu Penelitian
• Jakarta, 11 Juli 2006 – 11 Agustus 2006

Data Penelitian
• Buku Data Kejadian/Kecelakaan Pesawat TNI-AU
Dislambangjaau Januari 1995 –
Desember 2005
• Laporan PPKPT (6)
 Hasil Penelitian
• Januari 1995 – Desember 2005 :
53 incidents (total 322)
15 accidents (total 69)

• PPKPT : 6 kasus
- NAS-332 Super Puma, Ciamis (1999)
- S-58T Twin Pac, Bogor (2000)
- SA-330 Puma, Keibar (2000)
- Bell-47G Soloy, Subang (2002)
- S-58T Twin Pac, Bogor (2003)
- NAS-332 Super Puma, Wonosobo (2004)
Incidents
• Helikopter (Jan 95 – Des 05) : 53 kasus
• Faktor Penyebab :
- Materil → 43 kasus
- Media → 7 kasus
- Manusia → 3 kasus
• HFACS hanya pada kasus akibat
F.Manusia
 Tabel Hasil Penerapan HFACS pada Incident Helikopter
TNI-AU Jan 1995 – Des 2005
No Jenis Kegagalan/Kelemahan Jumlah
A. UNSAFE ACTS
Errors 3
a. Skill-based Error 3
- Inadvertent Operations 2
- Over/Undercontrol 1
- Breakdown in Visual Scan 1
b. Perceptions Error 2
- Error due to Misperception 2
c. Judgement & Decision Making 1
Error 1
- Necessary Action – Delayed
No Jenis Kegagalan/Kelemahan Jumlah
B. PRECONDITIONS FOR UNSAFE ACTS
1. Environmental Factor 3
a. Technological 3
- Visibility Restriction 2
- Instrumentation&Sensory Feedback System 1
2. Conditions of Individual 3
a. Cognitive 3
- Channelized Attention 3
b. Physical/Mental Limitation 3
- Anthropometric/Biomechanical 2
- Motorskill/Coordination/Timing Deficiency 1
c. Psycho-behavioral 2
- Overconfidence 2
d. Perceptual 2
- Misperception of Operational Condition 2
- Expectancy 2
3. Personnel Factor 1
- Cross-Monitoring Performance 1
No Jenis Kegagalan/Kelemahan Jumlah
C. SUPERVISION 3
1. Inadequate Supervision 3
- Local Training Issues 3
- Leadership/Supervision/Oversight 1
Inadequate 2
Planned Inappropriate Operation 1
- Crew/Team/Flight Make 1
Up/Composition
- Limited Total Experience
Historical Background
 regulasi

The Damage Tolerance Requirement

The Certification Requirement

FAR 25.571
Related Issue:

FAR 25.629(d) : Flutter

FAR 25.631 : Bird Strike
FAR 25.365 : Pressurization The Maintenance Requirement
FAR 25.903(e) : Rotor Burst FAR 25.1529
 regulasi
FAR 25.571(a)
General Requirement

(b) (c) (d)

Damage Tolerance Fatigue Sonic Fatigue

(e)
Discrete Source
Special Structure Special
Damage Tolerance Structure
Incapable
Most Structure
 Fatigue failure mechanism

CYCLIC
LOADING
CYCLIC
SLIP
CRACK
INITIATION
CRACK
GROWTH
FINAL
FAILURE
 DAMAGE TOLERANCE

DEFINITION

Damage Tolerance concept means that the structure has

been evaluated to ensure that should serious fatigue,
corrosion, or accidental damage occur within the
operational life of the airplane ,the remaining structure
can withstand and reasonable loads without failure or
excessive structural deformation until the damage is
detected
OBJECTIVES

The objectives of damage tolerance evaluation is to answer the

following questions

 How long does it take for a crack to grow from certain

initial size to critical size ?
 What is the residual strength as a function of crack size ?
 What is the critical size ?
 How often should the structure be inspected for crack ?

THESE ANSWERS WILL BE APPLIED IN MAINTENACE

PROGRAM
TASK OF FATIGUE AND DAMAGE TOLERANCE EVALUATION

DEFINE PRINCIPAL STRUCTURAL ELEMENT

( P.S.E)
– DEVELOP FATIGUE LOAD/STRESS SPECTRA
– FATIGUE ANALYSIS
– CRACK GROWTH ANALYISIS
– RESIDUAL STRENGTH ANALYSIS
– INSPECTION
– METHOD OF INSPECTION
analisis
analisis
Load spectrum
 Load spectrum
exceedance curve due to gust

2
Nz

1 Series1

0
1 10 100 1000 10000

-1
cumulative occurence
 putaran propeller
mengakibatkan beban
dinamis

retak awal terjadi

seketika
 Discreasing Failure rate Bathtube curve
Infant Mortality Periode Increasing Failure rate
Where Debugging is Talking Sistem/Equipment Wear-Out
Place Periode
Where Increasing
Maintenance is Required
Constan Failure rate
Region
Expontial Failure Law
Applies
F
a
i
l
u
r
e

R
a
t
e
time
BATHTUB CURVE (FAILURE CLASSES)
 Karakteritik Kurva Hidup Sistem
Bentuk kurva kamar mandi “bathtub hazard rate
curve” yang dibagi tiga area A, B dan C.
* Area A disebut sebagi burn-in region atau
Decreasing failure rate during debugging
* Area B = Useful life region atau Constant failure
rate region
* Area C adalah wear-out region atau increasing
failure rate during “wear-out”.

Pada fase A umumnya terjadi penurunan tingkat

kerusakan, B laju kerusakan konstan dan C laju
kerusakan meningkat sampai pada masanya
sistem tersebut tidak dipakai lagi (mati).
 Fase Burn in Bathtube region analysis
• Fase Awal, disebelah kiri diawali dengan tingkat
kegagalan tinggi namun laju kurva menurun tajam
sampai pada batas normal. Tingkat kegagalam ini
kemungkinan karena adanya kerusakan pada saat
perakitan, transportasi dan penyimpanan yang
tidak semestinya. Adanya bagian-bagian yang
hilang, pengukuran yang tidak tepat maupun
sistem inspeksi yang tidak teliti akan
menyebabkan usia pemakaian yang pendek
sehingga sebelum dioperasikan tingkat kegagalan
komponen sudah tinggi.
Alasan-alasan terjadinya “Burn-in region”
No. Reasons
1 Inadequate quality control
2 Inadequate manufacturing methods
3 Substandart materials and workmanship
4 Wrong start-up and installation
5 Difficulties because of assembly
6 Inadequate debugging
7 Inadequate processes and human eror
8 Inadequate handling methods and wrong
packaging
Fase Useful life
• Fase Konstan, bagian ini mendominasi kurva
yng berbentuk datar pada tingkat paling
rendah, dimana tingkat kegagalannya bersifat
random (acak). Kegagalan pada umumnya
disebabkan pengaruh eksternal, misalnya
salah mengoperasikan, kecelakaan, getaran,
akibat kenaikan temperatur yang mendadak
maupun pengaruh kelembaban. Pada bagian
ini tingkat kehandalan komponen adalah
tinggi, sehingga dapat dioperasikan secara
optimal dan ekonomis karena jarang terjadi
penggantian komponen.
 Alasan-alasan terjadinya kerusakan
“useful-life region”
No Reasons
1 Cause whice cannot be explained
2 Human errors, abuse, and natural failures
3 Unavoidable failures : this cannot be avoided by
even the most effective prefentive maintenance
practices
4 Undetectable defects
5 Low safety faktors
6 Higher random stress than expected
Fase Wear out

• Fase Akhir, adalah akhir dari pengoperasian

komponen yang ditandai dengan semakin
banyaknya kerusakan karena jam pemakaian
yang tinggi, antara lain adanya korosi,
bagian-bagian yang patah, retak karena
proses kelelahan dan difusi material. Bentuk
kurva cenderung naik dengan tajam.
Alasan-alasan terjadinya kerusakan
“Wearout region”
No Reasons
1 Inadequate maintenance
2 Wear due to friction
3 Wear due to aging
4 Wrong overhaul practices
5 Corrosion and creep
6 Designed-in life of the product is short.
Kurva Bathtube untuk komponen yang lain

Electronic Mechanical
Equipment Equipment
 ANALYSIS

Analyze, as appropriate, only the

information documented in Factual
information and which is relevant to
the determination of conclusions
and causes.
 CONCLUSIONS

List the findings and causes

established in the investigation.

The list of causes should include both

the immediate and the deeper systemic
causes.
 SAFETY
RECOMMENDATIONS

As appropriate, briefly state

any recommendations made for
the purpose of accident
prevention and any resultant
corrective action
 Kesimpulan

a. Modus-modus kegagalan komponen pesawat udara dapat berasal dari manusia

yang mengoperasikan, rangkaian komponen dalam sistem ataupun dari “enviroment”
yang tidak dapat diprediksi dengan pasti.

b. Sistem “tools” yang tersedia akan empengaruhi dalam penemuan modus kegagalan
komponen yang independent terhadap komponen lainnya dalam satu sistem.

c. Beberapa software seperti damage tolerance, fatigue monitoring maupun nastran

atau ANSI dapat membantu dalam menemukan tendensi kegagalan komponen.

d. Dengan memahami lebih detail bagaimana komponen berinteraksi dalam

membentuk sistem, maka metode Reliability Block Diagram dapat menerangkan
dengan jelas tentang bagaimana sistem disusun dari komponennya.

e. Kegagalan komponen biasanya tidak bersifat independent, karena itu perlu dipahami
lebih mendalam tentang diagram rangkaian sistem yang menggambarkan
bakaimana kontribusi masing-masing komponen dalam membentuk suatu sistem.
 Saran
 Modus kegagalan komponen pesawat udara dapat
ditemukan dengan mudah apabila dioptimalkan
software analisis yang ada dan dibekali pelatihan
yang intensif.


Modus kegagalan komponen bisa ditemukan dari cara
investigasi, ketersediaan data dan historical record
masing-masing komponen tersebut.


Harus ditemukan modus kegagalan kritis dan independent,
karena biasanya modus kegagalan ditemukan sebagai
akumulasi beberapa kegagalan komponen yang saling
berkaitan sehingga sulit dianalisis.