Susi Air Crash Indonesia 2012 Porter PC6

With now the third fatal accident in some nine months, serious questions are being asked again about Susi Air and its regulators or lack of them.

After a recent trip to Bangkok, I caught up with a previous colleague as we regularly do when we cross paths. I entertain in Hong Kong, he looks after the Bangkok nights. In the conversation over a few beers Susi Air came up, he told me about a report that came across his desk predicting this latest fatal crash. It also included evidence of an incompetent DCGA of Indonesia and a blatant disregard to safety in the airline. Due to the wonders of modern technology and finally Thailand’s entry into 3G I was reading it from my iPhone only 5 mins later. The copy that was sent to me, had some hand written notes on it, and more variations of confidential stamps plastered all over it than I never knew existed. Right then and there I decided it was the right thing to leak this. Fortunately I didn’t publish it to the world that night. How ever I have decided to publish much of it directly and paraphrase some of the longer recommendations.

Susi Air in 9 Sept 2011 had a fatal CFIT Controlled Flight Into Terrain, (possible loss of control) the weather at departure was reported as very bad and is believed to be a contributing factor. The recovery of the bodies of the victims were delayed due to thick fog and bad weather.

Susi Air Porter About To Take Off

Susi Air Porter About To Take Off
Image: CC Att SA 3.0 Author : Pa34

Seventy five days later on 23 Nov 2011 another fatal accident when a aircraft appears to have conducted a botched missed approach due to an obstacle on the runway, the crew lost control of the aircraft and crashed.

After this accident, a report emerged regarding the disgusting safety culture and many detailed events at the airline that should have had alarm bells ringing, I believe this was not published to the public but was sent to Susi Air, DCGA & ICAO.  Had the Airline or the DGCA of Indonesia followed basic international standards or their own rules that  this report suggest was not happening, the 3rd fatal would certainly have been avoided. If only the 3rd victim Mr Ian McDougalls employer PT Surtech Utama actually knew this. I believe they defiantly were trying to do the best for their staff.  Mr Neubecker said his company used Susi Air extensively because its fleet was new, with high quality aircraft that were well maintained.

Sadly little did he know what was behind the glossy paint job, well oiled salesman and the reality of the maintenance. The original concept when Susi was started of trying to break the typical local company accident rates by buying new machines and bring in western expats to fly them who had a different mentality was valid, how ever, industry insiders said the pressure of the dollar succumbed Susi Air after a trouble free beginning where they gained a good reputation as being “different”, they ended up being very “special” indeed. It was a popular plane as some of the Porters have a under fuselage door which is handy for aerial photography and survey.

The report I received suggests that the company might be insolvent while servicing an enormous debt. A strong safety culture is far from a priority there now it claims, it is all about paying the banks, pay the local staff then middle of the next month look at paying the expats staff. For many, it doesn’t seem to matter, as the foreign pilots are there for flight hours and defiantly not the money, or lack of it. The company is seen regularly advertising for low experienced pilots in Australia, basically an ideal first opportunity to get hours. A previous pilot employee told me the the fact is, many of the pilots that go make significantly less income flying for Susi Air than they could make in McDonalds flipping burgers, all in the hope of getting hours to get a job in a decent company if they survive the Susi ride.  Insiders suggest, there is only one Caravan in their fleet with a Cockpit voice recorder. That is required by Part 135.  Again no money is inferred. .

When I skyped a friend who got his first break at Susi Air for a chat this morning, I had chills run down my spine. He has since moved on and is now working for a normal company in Hong Kong, how ever, he spoke of wide spread “Push-On-itis” at Susu Air, with excessive pressure coming from all angles at you, referring to a disease type of mentality where you just keep going, when you know there is high risk when you are carrying many “snags” (unserviceable systems) you shouldn’t be, or pushing into marginal weather VFR or continuing IFR when you now your alternates also have weather issues. His described it as “the norm” there. He continued on saying it is just a part of life at Susi, every one does it day in and day out, you don’t even feel like you are breaking basic safety standards after a while. He told me, “if you don’t fit in to the Susi way, you will be shipped out the Susi way”. When I asked about were you worried of getting caught from authorities, he just laughed. I think that says it all. He did point out that he made some really good buddies though and had great time there, it also introduced him to Asia which he is still thank full of. His quote is worth finishing up with though, “The general safety culture is rotten to the bone” he told me.

It is worth noting that the porter is one of those special planes, a bit like the Twin Otter They are the rugged bushman’s plane that can go to to some strips that not much else can get into. These two machines can pay well, and I do understand why some pilots do specialize in the environments these planes do so well in. It is a testament within it self that the two types are both still in production today.

Below is a summery of the report, shortened to make it easier to read. I am not interested in identifying staff members and have censored their names with random initials. It makes reference that the DCGA of Indonesia will not touch or enforce any laws pertaining to Susi Air. My pilot friend said, “All the crew know they will never be punished under the law as there is enough political friendships”. The report is somewhat “politically correct” and does not straight out accuse of mass corruption in the face of basic safety standards being abused, but I will let you be the judge. But you may be in good company, with the FAA, ICAO and EU. The FAA has blasted the Indonesian DCGA saying, “is not in compliance with ICAO safety standards for the oversight of Indonesia’s air carrier operations.”

The Australian Government has issued a warning on Susi Air in particular on 01 May 2012.

“Fatal air crashes involving the Indonesian carrier Susi Air occurred on 9 September 2011, 23 November 2011 and 25 April 2012. Australian officials in Indonesia have been directed not to use Susi Air for official travel until further notice.”

I have more information with link down the bottom of this article on the above subject.

Summary Of the Noted Report – Susi Air

Dated 5th January 2012

Recommendation 1: “It is clear that Susi Air does not have the required personnel under Part 135. It has names on paper but no actual person fulfilling the duties of the post. As such Susi Air is not fit to hold an AOC under the terms of Part 135.”

Recommendation 2: “That the only course of action is to suspend operation of Susi Air until all required post holders are recruited and put in place with full authority to act as necessary. This action would put people who actually know what they are doing in charge and by doing so would address a large part of the problem at Susi Air.”

Recommendation 3: “The senior management both expat and local are not fit to run this operation. The experience level is too low and the courage and ability to make decisions is totally lacking. I see no single person below the position of Director of Operations who has not succumbed to the fear culture of Susi Air installed by the CEO and the Director of Operations. They are all afraid to stand up and be counted because they all know that to do so will see their departure from the organisation”

Recommendation 4: Goes on quoting the Susu Air HR Manager “IM” (name censored as this is a summary about the company more than individuals), saying, “that we do have named post holders”. When the HR manager was asked, where is the Susi Air Chief Inspector, the answer was, “in Jakarta in Rehab”. The Susi Air Chief Inspector, Mr “PH” is a drug addict and certainly not a fit and proper person for that position. Again, just another name of paper.

His AMEL # 5676 according to company records expired in June 2011. He has no recent experience of aircraft maintenance work. According to the Company Maintenance Manual his functions include, quality audit, quality control functions, including maintenance and material inspection, he is also responsible for administering the safety program.”

The report suggest that this person is incapable of any of the above functions under normal circumstances.

“This raises the question of why do the DGAC all Susi Air’s co-founder and director of operations allow this? The answer is clear the DGCA have no authority over this operation.” [My Bold]

Recommendation 5: “In terms of engineering Susi Air does not have an active quality department.” Goes on with details of “elusive” people and lack of training.

Recommendation 6: “There is no safety manager and therefore no oversight of the safety of the Susi Air operation. Again there are names on pieces of paper. However names on paper are worthless. Once again the DGCA turn a blind eye to these critical posts being unattended.”

Recommendation 7: “Chief pilot fixed wing “AH” is a local line pilot. He may not actually know that he is the named chief pilot. He has no physical office. He has no control over SOP’s or the dangerous goods manual. He is in fact flying in Kalimantan and has been for some months. In the COM his job description states he is responsible for managing and controlling fixed wing aircraft crew members and maintaining safe, professional flight standards. This must be difficult if not impossible while flying in Kalimantan. He is another totally ineffective person.”

Recommendation 8: “The DGCA appear to be unaware of this. The oversight of Susi Air by this authority is totally lacking and totally unacceptable. This lack of oversight is risking the loss of innocent life.”

Recommendation 9: Goes on in detail regarding how many engineering training certificates are suspect with graphic details.

Recommendation 10: Following up the above recommendation, the courses proposed are not in English for English speaking expat qualified staff bought in.

Recommendation 11: Related to the above two issues, stating the Susi Air CEO will not approve the budget for a person to full fill that role to be employed.

Recommendation 12: “Susi Air has issued some certificates for a very questionable PC 6 Porter Type Course in 2011. My understanding is that the instructor had never worked on a Porter PC6 or done an approved course.” Single Engine aircraft operating in harsh terrain.

Recommendation 13: “The bottom line is with seriously lacking training records I am not able to confirm how many engineers at Susi Air are legally able to release to service. The Chief Inspector is not.“

Recommendation 14: Goes on to talk about poorly equipped training rooms for flight operations.

“The room is ill equipped and a health and safety hazard. In any normal circumstance it would not be considered fit to use as a classroom. The situation regarding any training at Susi Air is nothing like normal”

Recommendation 15: Is very long, discussing observations of aircraft ground crew that are not legal, with out training, a power struggle between departments who control them, regularly carrying dangerous goods and the staff not trained and certified to do so. Goes on to talk about a recent incompetence example of a aircraft being refuelled with a large amount of water and suspected lack of proper reporting of accidents and incidences.

Recommendation 16: Questioning the viability of an additional 10 proposed routes as the company rapidly expands.

Recommendation 17: Discuses marginal flight safety ad lack of organisational structure.

Recommendation 18: Discuses the high risk of the 3rd accident.

Recommendation 19: “Up to now Susi Air has lost the life of 3 pilots, destroyed the career of a fourth and totally written off 2 hulls, this in the space of just 75 days. I have not seen a single piece of paper referring to an accident investigation for either incident. The DGCA seem to have been silent apparently not checking personnel records or aircraft maintenance logs. The two incidents have been swept away leaving the organisation and the DGAC no wiser as to where and when the next fatality will occur. Nothing has been learned by implementing the company safety Management System”

Recommendation 20: “The Susi Air Safety Management system is totally dysfunctional. It should have been used as a tool to aid the organisation in learning from the mistakes which led to the loss of two aircraft.” Investigations indicate, “Instead it has been left sitting on a shelf where it has been since February of 2009 gathering dust.”

Recommendation 21: “Susi Air is operating its engines on an extended life cycle, based on regular Engine trend monitoring. Investigations revealed that Susi Air Human Recourse Department refused to pay the salary for a qualified person to do the engine trend monitoring as a consequence Engine trend monitoring is currently not being done. Susi Air has yet to advertise for this very important function to be filled. The risk of a single engine failure is increasing with every hour flown. As this is a single engine operator the risk of a forced landing and all of its associated consequences is also increasing.”

Recommendation 22: “All of the above leaves me believing that Susi Air has no choice but to cease operation at least temporarily.” This would be a problem as the company is already late paying wages to some expats and bills, the result would be almost bankruptcy. Just ask some of the like creditors like Pacific Aero who it was well known in the industry were out of pocket over a quarter of a million USD, and not at all happy about it.

Recommendation 23: Questioning the DGCA involvement or lack of it.

Recommendation 24: “If nothing is done to control this company the risk of loss of life is probably now extremely high and beyond a level which is acceptable in any risk management system. “

End of my summary of the report.

There are questions being asked if Susi Air has broken other laws relating to a second passenger, Major Sus Widodo, got off the plane just before it took off because he had a headache. I am not sure of the law my self, but apparently this flight should never had been dispatched with out the Indonesian Government observer as required on such survey flights for national security reasons. It is non the less one very lucky Major Sus Widodo walking around today. 

On the latest crash, which occurred after relevant authorities received this report as well as the company, it is reported that the Australian passenger Mr Ian Mcdougall had time to send an SMS message to his employer, saying the plane had fuel problems.

Mr Von Strombeck, Susi Air’s co-founder and director of operations, said regarding this crash, early investigations suggested the plane had sufficient fuel in its auxiliary tanks to fly for up to two more hours but that the fuel was not being delivered to the engine. Mr Von Strombeck said the plane had not run out of fuel, but fuel management may have been a contributing factor, indicating the possibility of pilot error.

The fact that the passenger had time to write a text message indicates to me the pilot had more than sufficient time for an emergency relight (re start) of the engine had the fuel been able to be delivered to the engine. I am not an expert on the auxiliary fuel system on the Porter and not aware of what pumps or systems are required to transfer the fuel to be delivered to the engine, how ever these were new planes that would have had updated warning systems on board. Susi Air indication to point the finger at a dead expat South African pilot Jonathan Willis is not surprising as the report indicates that a thorougher investigation had not been carried out on the other two fatal crashes which appear likely to be pilot error / weather related.  Hopefully this does not avoid the likelihood of a maintenance issue being properly investigated. The report gave details of where it says Susi Air have already had an incident where the un qualified ground crew put so much water in the fuel tanks the pilots could not start the engines on the Caravans.

Fuel contamination is unquestionably an issue, be it algae or sludge blocking fuel filters or water in the aux tanks that was delivered to the engine in such a large amount to cause it to fail and not re light. They were about 5 hours into a 6 hour flight which I believe requires aux tanks in the Porter.

It is worth also noting that in the tropics it is required to treat the fuel tanks at scheduled intervals with a fuel additive that kills algae growing in the tanks and fuel lines, typically this is done by filling all tanks with fuel and the additive and letting it sit for several hours before that same fuel is then used in flight, also clearing the fuel system of algae in the process. In operations where there is mainly short flights, it is difficult at best as this process replaces payload when the plane is full of fuel and hence cost money.  I only hope the aux tanks that are used for long flights were maintained the correct way. The report makes no reference to Aux tanks. Possibly, we shall never know, as there will continue to be a blind eye from authorities while the Susi Air ‘Russian Roulette’ continues……

I suspect Susi Air will continue to operate, I just hope this is the end of tragic accidents.

Finally, I decided in an effort to make it easier for all concerned to simply re publish what the Australian Embassy has warned its citizens of regarding Indonesia.  Most western countries are similar, I chose Australia as they have a warning naming Susi Air inparticularly , the only company they do.

Airline safety

Fatal air crashes involving the Indonesian carrier Susi Air occurred on 9 September 2011, 23 November 2011 and 25 April 2012. Australian officials in Indonesia have been directed not to use Susi Air for official travel until further notice.

The United States Federal Aviation Administration (FAA) through its foreign assessment program focuses on a country’s ability, not the individual airline, to adhere to international standards and recommended practices for aircraft operations and maintenance established by ICAO. The FAA has determined that Indonesia’s Directorate General of Civil Aviation (DGCA) is not in compliance with ICAO safety standards for the oversight of Indonesia’s air carrier operations. For more information, visit the FAA website. The US embassy in Jakarta has advised Americans travelling to and from Indonesia to fly directly to their destination on international carriers whenever possible.

The European Union (EU) has published a list of airlines subject to operating bans or restrictions within the EU. While all Indonesian airlines were included on the list in July 2007, four carriers ( Garuda Indonesia, Airfast Indonesia, Mandala Airlines and Ekspress Transportasi Antarbenua (trading as PremiAir) were taken off the list in July 2009. To see the list, visit the EU website.

CASA assesses the safety of all aircraft flying within, to and from Australia. CASA has certified Garuda Indonesia and Air Asia to operate flights between Australia and Indonesia. CASA cannot assess the safety of any Indonesian carriers operating within Indonesia or to countries other than Australia.

Message for U.S. Citizens: Indonesia, Safety Concerns with Susi Air     4-May-2012

Due to aviation safety concerns, U.S. Mission Indonesia informs U.S. citizens traveling to or residing in Indonesia that effective immediately, and until further notice, U.S. Embassy personnel are prohibited from flying on Susi Air.  Susi Air has suffered three fatal plane crashes in the last 12 months in Indonesia.  The most recent crash was on April 26, 2012, killing the pilot and one passenger.

 

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