RESPONSE BULLETIN From State Safety Program System
 Bulletin 1 October 2018 

RESPONSE From DGCA'S Voluntary Information for Safety Improvement in Aviation System ( VISION )

VISION is a voluntary reporting system for improvement of aviation safety in indonesia.Based of ICAO Standard , we gather information on actual or potensial safety defienciencies that may not be captured by the mandatory reporting system. We also share information which we analyze a voluntary report for aviation safety to aviation community as "Response Bulletin"

Large Aircraft / Air Navigation Service

1. Late Select Landing Flap On Approach
Content
We still 7000' Given direct to point for no 1 (one) in sequence, we establish ILS GS at 1000' but late to select landing flap, we prepare for go around, just about to do it we got everything under control and condition was very good and CAVOK so we canceled and we decided to land and landing safely.
Comments
It is important to adhere the concept of stabilized approach, flight management and air traffic flow management.
2. Glide Slope Unserviceable
Content
We are coming from MKS direct to AUDRI, metar ambon is rain RWY wet, and BKN covering almost the whole island. There are no traffic coming or departing from WAPP, we are cleared by atc to direct AUDRI and descend 4000ft. 7nm to AUDRI cleared for ILS RWY 04. We configure the aircraft until config 2 before AUDRI, Captain arm the approach and select ap1+2 on and we successfully intercept the localizer but there is no sign of G/S in PFD. Captain decide to descend 2000' and select gear down around 2000-3000ft. We ask tower is G/S serviceble and they say serviceble. We continue maintain 2000 and select config. 3 still hoping there will be G/S, but no G/S until FF04. We decide to do LOC only R/W 04 and select bird on and put FPA 3 degrees. I change the minimum on performance page to 750ft. Because we are to focus on the approach we forgot to select config full and establish config full around 600-700ft.
Comments
It is neccesary that the ATC confirm to ANSP technician regarding ILS monitoring checklist. And use the briefing form to report at Brefing Office.
3. Glide Slope Unreliable
Content
Glide slope UNRELIABLE (Out & Alive) when leaving AUDRI PIC realize that situation and took an action v/s 2000 fpm initial and maintain constant vertical speed 600-800 fpm during approach and disconnect autopilot before 1000 feet and we got runway insight at 2000 ft above, and the Tower controller did not inform us at all, they’re just confirmed if the glide slope serviceable or not just after we land
Comments
It is neccesary that the ATC confirm to ANSP technician regarding ILS status.
4. Go Around Due To Early Capture Indication
Content
On WIII, First approach ILS make GO Around due to indication too early capture. Second approach radar vector ILS, and landing safely.
Comments
Thank you for sharing your experience. In this case, the ILS capture might has gotten too soon for some reason. But we couldn’t analyze this event because of lack of the information. In order to analyze this event appropriately, we will ask everyone who have same experience to share more information.
5. Divert Due To A Hole Prior Touchdown Zone
Content
Divert due to aerodrome closed because of a hole prior to the touchdown zone, initially ATC stated that the inspection until 1015z. But after 60 minutes holding they stated the work will finish at 1115z, PIC decided to divert and landed safely.
Comments
We couldn’t analyze this event because of lack of the information. In order to analyze this event appropriately, we will ask everyone who have same experience to share more information.
6. Slow Respond On Communication To ATC
Content
Last night we difficult to establish contact with Jakarta frequency, we try to contact many times to ATC because we have weather on route but ATC slowly respon.
Comments
We couldn’t analyze this event because of lack of the information. In order to analyze this event appropriately, we will ask everyone who have same experience to share more information.
7. Almost Ground Nearmiss
Content
A widebody airplane almost hit another airplane tail on parking stand no 15 on UPG.
Comments
It is considered important for every pilot to follow taxi guide line during taxi and to increase situational awareness.
8. Wildlife Invasion On Runway
Content
Go-around RW31. On leaving IAF ATC say “an aircraft prepare for go-around due to animal on the runway” not sure weather we were asked to go around or simply prepare we continue and immediately ask if go-Around or prepare for go-around. ATC call back “prepare for go-around. Since the clearance was not clear. It initiated a cancel approach and requested to climb to 4500 feet and left turn to hold. On reaching it was cleared for approach. Landed safely on runway R/W 31. On landing confirmed by ground staff of a dog on the runway.
Comments
It is important for every airport to ensure the reliability of its perimeter fence. In this kind of situation, it is required a definite "go around" clearance from ATC to Pilots. Every pilot also need to maintain his self awareness during final approach.
9. Wildlife Invasion On Runway
Content
Make go around at 900’ instruct by ATC due to Big Pig on the runway and than we make another approach and landing safely.
Comments
It is important for every airport to ensure the reliability of its perimeter fence and to conduct wildlife hazard surveillance routinely in accordance with wildlife hazard management manual. In this kind of situation, it is required a definite "go around" clearance from ATC to Pilots. Every pilot also need to maintain his self awareness during final approach.
10. Aircraft Stuck Due To Hole In Runway
Content
From Sorong (SOQ) to Manado (MDC) an Airplane requests pushback from parking stand and start up. From ATC gives heading on runway 27. After that the airplane requests taxiing. Then from ATC give taxi clearance. Then taxi to runway 27. When airplane maneuver at runway 27. Pilot to the ATC that it can not continue maneuver because stuck, because of the hole. Pilot request towing car. Then ATC coordinates with AMC, and manager operation. It pushback to runway 27 to help the maneuver process.
Comments
It is important for aviation personnel to report the runway or taxiway surface condition if they found any abnormal condition to the airport operator. Based on that, the airport operator take immidiate action to inspect the condition and conduct mitigation.

Small Aircraft / Air Navigation Service

1. Pitot Tube Block By Insect
Content
A Cesna C172, at the take off phase, the air speed is not indicated so that we decide to aborted, after checking the engineer blocked on the pitot tube, the plane is after maintenance, although the pitot tube already on the cover, it can still be inserted by insects that cause pitot block. The incident repeated again with another plane up to 3 times.
Comments
Thank you for sharing your experience. It is considered important for small aircraft parked overnight especially in area infested with insect to ensure the proper installation of the pitot tube cover, and also with proper preflight check inspection.

Cabin / Mechanic / Airport / Other

1. Green Laser Attack
Content
When conducting VOR approach RW 29 on BDO, anyone who directed a green laser to us continuosly. His position is around radial 255 and 7DME from BDO VOR.
Comments
It is necessary for airport operator to conduct safety promotion to local government and the society around the airport to minimize the laser hazard.
2. Service Road Marking
Content
There is no marking for service road for vehicles from terminal entering apron. The existing service road is quite confusing because of the breaking of the marker line for the service road.
Comments
It is important for every airport operator to check service road marking regularly to ensure the marking is clear and visible.
3. Bad Visual Due To Wild Plant
Content
Bad RWY light visual condition on app due to covered by long grass at Djalaluddin Airport Gorontalo (GTO).
Comments
It is important to maintain the height of the grass on runway strip regularly.
4. Accidentally Crossing Red Area
Content
Accidentally crossing red area (read NOTAM info for apron work in progress ) due to confusing for following yellow line, many line on the apron including yellow steady line, yellow dash line, removed cross line with gray color, yellow cross line, and red area.
Comments
It is necessary for the airport operator to recheck the marking on the apron and the air operator recognize the functions of the marking on the apron.
5. Taxi Guide Line And Runway Center Line Not Clearly Visible At Night
Content
Taxi guide line and runway centre line marking not cleary visible at night in Halim Perdana Kusuma Airport (WIHH)
Comments
It is essential that every airport operator to recheck the taxi guide line and runway center line marking of airside facility.
6. Aircraft Stuck On Taxiway Due To Bad Surface Condition
Content
Aircraft Stuck during taxy out from taxiway B at Juwata - Tarakan due to bad surface condition, need assistance from towing car.
Comments
It is important for aviation personnel to report the runway or taxiway surface condition if they found any abnormal condition to the airport operator. Based on that, the airport operator take immidiate action to inspect the condition and conduct mitigation.
7. Ground Vehicle Engine Trouble
Content
A loud voice on BUS that we use to go to post boarding plane on gate door 2. The loud voice comes from the bottom of the vehicle chassis
Comments
It is important that ground handling operator to conduct regular maintenance on their vehicle.
Category Issued in Bulletin 1
Category No. of Alerts
Large Aircraft / Air Navigation Service 10
Small Aircraft / Air Navigation Service 1
Cabin / Mechanic / Airport / Other 7
Estimated Factor
Primary Factor 18
Related Factor 54
Human Factor 54


DGCA's Voluntary Information   |  vision_ssp@dephub.go.id  |  081310087600
http://ssp.hubud.dephub.go.id
Bulletin 1