Accident Embraer ERJ 190-200 LR (ERJ-195LR) PK-KDC, Monday 21 December 2015
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Date:Monday 21 December 2015
Type:Silhouette image of generic E190 model; specific model in this crash may look slightly different    
Embraer ERJ 190-200 LR (ERJ-195LR)
Owner/operator:KalStar Aviation
Registration: PK-KDC
MSN: 19000057
Year of manufacture:2006
Total airframe hrs:16862 hours
Cycles:14765 flights
Engine model:General Electric CF34-10E7
Fatalities:Fatalities: 0 / Occupants: 125
Other fatalities:0
Aircraft damage: Substantial
Location:Kupang-El Tari Airport (KOE) -   Indonesia
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Ende-H. Hasan Aroeboesman Airport (ENE/WATE)
Destination airport:Kupang-El Tari Airport (KOE/WATT)
Investigating agency: NTSC
Confidence Rating: Accident investigation report completed and information captured
An Embraer ERJ-195LR operating KalStar Aviation flight KD676 suffered a runway excursion on landing at Kupang-El Tari Airport (KOE), Indonesia. The aircraft sustained substantial damage. There were no injuries among the two pilots, three flight attendants, and 125 passengers.
Flight KD676 departed Bali/Denpasar at 15:34 with a delay of 74 minutes due to late arrival of the aircraft from the previous flight. Destination was Kupang with a stop at Ende. On the flight from Bali to Ende, the captain acted as pilot monitoring (PM) and the copilot acted as pilot flying (PF).
While on approach to Ende, at a position about 5 minutes out, the captain commanded to delay speed reduction and shortened the approach. This action was intended to speed up the flight, considering the Ende airport operating hours. The aircraft landed in Ende at 16:39.
During transit, the captain received a short message from a flight operations officer of Kalstar Aviation in Kupang which informed him that the visibility at Kupang was 1 km. Considering the weather forecast in the Terminal Aerodrome Forecast (TAFOR) showed that the visibility at Kupang would improve at the time of arrival, the captain decided to depart to Kupang. Another consideration was the operating hours of Ende which would be closed at 17:00.
The operating hours of Ende was extended and the aircraft departed Ende at 17:16. Again the captain acted as PM and the SIC acted as PF. There was no departure briefing performed by the PF.
After takeoff, the pilot set the Flight Management System (FMS) to fly direct to KPG VOR and climbed to a cruising altitude of FL175.
During cruise flight, the pilots monitored communication between the El Tari Tower controller and another pilot. El Tari Tower advised that the visibility at Kupang was 1 km while the minima for approach was 3.9 km. At 17:27, the pilot established communication with El Tari Tower controller and requested for direct to initial approach point SEMAU.
At 17:32 the aircraft started to descend to 10,000 feet. When the aircraft passed FL150, the pilot requested to turn left to fly direct to the inbound track of the VOR/DME approach for runway 07 in order to avoid cloud formation which was indicated by magenta color on the aircraft weather radar.
At 17:41, the El Tari Tower controller informed that the visibility on runway 07 was 4 km and issued clearance for an RNAV approach to runway 07 and requested that the pilot report when the runway was in sight.
Both pilots discussed the plan to make an RNAV approach to runway 07, with landing configuration with flap 5 and auto-brake set to position low. At 17:43, the pilot reported that the runway was in sight when passing 2,500 feet and the El Tari Tower controller informed that the wind was calm and issued a landing clearance.
During the approach, the PF noticed that all Precision Approach Path Indicator (PAPI) lights indicated a white color, which indicated that the aircraft was too high for the approach. Recognizing that the aircraft was too high, the crew performed a non-standard configuration setting by extending the landing gear down first with the intention to increase drag. The landing gear was extended at approximately 7 NM from the runway 07 threshold and afterwards selected the flaps to 1 and 2. The published approach procedure stated that the sequence for establishing landing configuration is by selecting flap 1, flap 2, landing gear down, flap 3 and flap 5.
On final approach, the crew noticed the aural warning "HIGH SPEED HIGH SPEED". The copilot also noticed that the aircraft speed was about 200 knots, which was about 62 knots higher than the target speed. The pilots decided to continue the approach considering the runway was 2,500 meters long and would be sufficient for the aircraft to stop with the existing conditions. The pilots compared the runway condition at Kupang with the condition at Ende which had 1,650 meter length runway.
On short final approach, the aircraft was on the correct glide path and the speed was approximately 205 knots. The PF noticed the Enhanced Ground Proximity Warning System (EGPWS) warning of "TOO LOW TERRAIN" activated. The aircraft then touched down at approximately the middle of the runway. After touchdown, the PF immediately applied thrust reversers.
Realizing that the aircraft was about to overrun the end of the runway, and with the intention to avoid the approach lights on the end of the runway, the captain turned the aircraft to the right.
The aircraft stopped approximately 200 meters from the end of runway 07.

Contributing Factors:
- The steep authority gradient resulted in lack of synergy that contributed to least of alternation to correct the improper condition.
- Improper flight management on approach resulted to the aircraft not fully configured for landing, prolonged and high speed on touchdown combined with low brake pressure application resulted in insufficient runway for deceleration.
- The deviation of pilot performance was undetected by the management oversight system.


08:00 UTC / 16:00 local time:
WATT 210800Z 19003KT 7000 -RA FEW015CB BKN015 27/25 Q1010 RMK CB OVER THE FIELD

08:30 UTC / 16:30 local time:
WATT 210830Z 16005KT 7000 FEW015CB BKN014 27/25 Q1010 RERA RMK CB OVER THE FIELD

09:00 UTC / 17:00 local time:
WATT 210900Z 21022G34KT 0500 RA FEW014CB BKN013 25/23 Q1011 RMK CB OVER THE FIELD

09:30 UTC / 17:30 local time:
WATT 210930Z 24009KT 0500 TSRA FEW014CB BKN013 24/22 Q1012 RMK CB OVER THE FIELD

10:00 UTC / 18:00 local time:
WATT 211000Z 00000KT 2000 -RA FEW014CB BKN013 24/23 Q1012 RMK CB OVER THE FIELD

Accident investigation:
Investigating agency: NTSC
Report number: KNKT.
Status: Investigation completed
Duration: 9 months
Download report: Final report




photo (c) NTSC; Kupang-El Tari Airport (KOE); 21 December 2015

photo (c) NTSC; Kupang-El Tari Airport (KOE); 21 December 2015

photo (c) NTSC; Kupang-El Tari Airport (KOE); 21 December 2015

photo (c) NTSC; Kupang-El Tari Airport (KOE); 21 December 2015

Revision history:


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