AVIATION/ NTSC REPORTS ON MANDALA FL91

The Indonesian National Transportation Safety Committee, NTSC, has released its final report into the crash of MANDALA AIRLINES Flight 91 on September 5, 2005, at Medan, Indonesia. On that date, Flight 91 was on Domestic Boeing 73 Service from Medan to Jakarta, with 112 passengers and 5 crew members onboard. On takeoff, the 737 became briefly airborne, and then settled back on to the runway 23. The aircraft then overran the runway, and impacted buildings before coming to a stop on a public road, about 550 meters past the end of the runway. Upon impact with the buildings, the aircraft burst into flames. Of those onboard, 95 of the 112 passengers, all 5 crew members, and 49 people on the ground, were killed in the crash. Of the survivors, 15 passengers suffered serious injuries, while 2 passengers, a Mother and child, were not injured. At least 29 people on the ground also suffered serious injuries.

In their Final Report, the NTSC said that the accident was caused by:
1. The 737 took off with improper takeoff configuration, namely with retracted flaps and slats, which caused the failure of the aircraft to liftoff. (The NTSC recovered parts of the slats and flaps from the wreckage, and both were set in the retracted position).
2. Improper checklist by the crew, which led to the failure of the crew to determine that the flaps and slats were not properly configured.
3. The aircraft takeoff warning horn was not heard on the CVR recordings. The NTSC said that it was possible that the warning horn was not operational.
The NTSC added that they were unable to determine whether it was the Captain or Co-Pilot that was Pilot flying. They also added that the engines were not a problem and that the takeoff weight and balance were both in normal limits and not a factor in the crash. Full details on the crash, including the events from the aircrafts takeoff run thru the crash, can be found on the NTSC website.