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Display 565 of 22 row(s)| Instansi Penerima | Rekomendasi | Tanggapan | Status | Final Report | Tanggal |
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Instansi Penerima | Rekomendasi | Tanggapan | Status | Final Report | Tanggal | |
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| 2024 - Anjlokan KA 75A di emplasemen Stasiun Tanggulangin Daop 8 Surabaya tanggal 14 Januari 2024 | ||||||
| Direktorat Jenderal Perkeretaapian | Memastikan pedoman pemeriksaan dan perawatan wesel mekanik dapat mendeteksi kondisi komponen penguncian secara menyeluruh | Open | 2024 | |||
| Direktorat Jenderal Perkeretaapian | Melakukan pengawasan terhadap kondisi geometri jalan rel khususnya pada jalan rel di area sekitar wesel. | Melakukan pengawasan dan mengirim surat teguran kepada PT KAI (data dukung terlampir)DJKA telah melakukan monitoring dan evaluasi tindak lanjut rekomendasi KNKT dan surat teguran Direktur Jenderal Perkeretaapian | Closed | 2024 | ||
| PT Kereta Api Indonesia (Persero) | Mereview pedoman pemeriksaan dan perawatan wesel mekanik agar dapat mendeteksi kondisi komponen penguncian secara menyeluruh | Sedang dilakukan review pedoman pemeriksaan dan perawatan wesel mekanik agardapat mendeteksi kondisi komponen penguncian secara menyeluruh denganmenambahkan checklist eksternal locking pada wesel.Untuk langkah pencegahan kejadian yang sama, PT KAI telah melakukan:1. Pemasangan sabuk pada lock box rencana pengadaan External Locking padatahun 2024 secara bertahap.2. Pemeriksaan keretakan lockbox dengan dye penetrant. | Closed | 2024 | ||
| PT Kereta Api Indonesia (Persero) | Mereview potensi bahaya terkait kondisi geometri jalan rel khususnya di area sekitar wesel agar dapat menilai risiko dan langkah-langkah mitigasinya | 1. Melaksanakan kegiatan pemeriksaan dan perawatan di Emplasemen StasiunTanggulangin.2. Melakukan pengukuran dan perbaikan di belakang wesel (skilu belakang wesel).3. Menginput hasil pemeriksaan ke dalam format IBPR. | Open | 2024 | ||
| PT Kereta Api Indonesia (Persero) | Melakukan refreshment training secara berkala kepada petugas operasional pelayanan KA terkait interlocking pada sistem persinyalan perkeretaapian | Tim MT telah melakukan penyesuaian kurikulum dan silabus Diklap Modul Terpadu pada Kondisi Tertentu (Gangguan) dengan menambahkan mata latih Filosofi/Fundamental Tindakan pada Saat Kondisi Tertentu. | Closed | 2024 | ||
| PT Kereta Api Indonesia (Persero) | Mereview prosedur terkait pelayanan KA, khususnya untuk persinyalan mekanik, ketika terjadi gangguan sinyal agar dapat mengatur secara jelas langkah-langkah untuk memastikan/ meyakinkan kedudukan wesel | 1. Telah dilakukan revisi terhadap PDPS Stasiun Tanggulangin2. Pembuatan Instruksi Kerja (IK) Pelayanan Perka dalam Kondisi Tidak Normal di setiap stasiun.3. Saat terjadi Gangguan Sinyal Utama, pelayanan KA menggunakan MS (Btk 92) sesuai dengan PD 19 Jilid I pasal 49 dan Instruksi Direksi Nomor O.250. | Closed | 2024 | ||
| PT Kereta Api Indonesia (Persero) | Memastikan keandalan peralatan luar ruangan, khususnya media transmisi (saluran kawat dan roda kawat) untuk wesel dan sinyal mekanik | Unit Sintelis Kantor Pusat akan melakukan Bimtek ke daerah untuk menyamakan pemahaman terkait perawatan dan pemeriksaan peralataan persinyalan mekanik | Open | 2024 | ||
| 2024 - Tabrakan KA 350 (Commuter Line Bandung Raya) dengan KA 65A (Turangga) di Km 181+700 petak jalan antara Stasiun Cicalengka - Stasiun Haurpugur tanggal 5 Januari 2024 | ||||||
| Direktorat Jenderal Perkeretaapian | Memastikan tersedianya prosedur terkait pelayanan peralatan blok yang menggunakan sistem interface yang menghubungkan blok mekanik dengan blok elektrik. | DJKA melalui Balai Teknik Perkeretaapian Kelas I Wilayah Bandung telah meminta pabrikan IBM untuk menyusun manual produk, instalasi, maintenance/troubleshooting dan testing yang akan diinstalasikan pada pekerjaan Pembangunan Sistem Persinyalan dan Telekomunikasi Jalur Ganda KA antara Kiaracondong - Cicalengka Tahap II Segmen Kiaracondong - Gedebage dan Haurpugur - Cicalengka. | Open | 2024 | ||
| Direktorat Jenderal Perkeretaapian | Memastikan keandalan sistem interface yang menghubungkan blok mekanik dengan blok elektrik. | DJKA melalui Balai Teknik Perkeretaapian Kelas I Wilayah Bandung telah melakukan Pengetesan dan Dokumentasi Produk IBM sebagai bagian sistem interface yang menghubungkan blok mekanik dan blok elektrik di dalam pekerjaan Pembangunan Sistem Persinyalan dan Telekomunikasi Jalur Ganda KA antara Kiaracondong - Cicalengka Tahap II Segmen Kiaracondong - Gedebage dan Haurpugur - Cicalengka padda tanggal 7 Mei 2024. DJKA telah menegur PT. KAI untuk mengajukan permohonan pengujian peralatan persinyalan ke DJKA dan pada rapat ranggal 7 Mei 2024, PT KAI telah menyampaikan akan mengajukan permohonan tersebut. | Open | 2024 | ||
| Direktorat Jenderal Perkeretaapian | Meningkatkan pengawasan terhadap pelaksanaan sistem manajemen keselamatan perkeretaapian khususnya terkait sistem pelaporan potensi bahaya serta penilaian dan pengendalian risiko. | Pengawasan penerapan SMKP penyelenggara perkeretaapian secara sistem dilaksanakan dalam mekanisme audit SMKP (keselamatan) yang secara berkala dilakukan DJKA pada setiap Penyelenggara Perkeretaapian. DJKA telah melaksanakan audit keselamatan di PT. KAI (Persero) pada tahun 2021 namun dalam pelaksanaannya audit tertunda karena terjadinya kecelakaan KA yang merupakan peristiwaa yang kritikal di dalam SMKP. Audit SMKP kepada PT. KAI dilakukan kembali di tahun 2024 dan saat dalam tahap menunggu surat tanggapan dari PT KAI dengan batas waktu 30 hari kerja sejak 5 Juni 2024. | Closed | 2024 | ||
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Display 808 row(s)| Instansi Penerima | Rekomendasi | Tanggapan | Keywords | Kategori | Status | Final Report | Tanggal |
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Instansi Penerima | Rekomendasi | Tanggapan | Keywords | Kategori | Status | Final Report | Tanggal | |
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| 2024 - Other, Batik Air Indonesia (Airbus A320/PK-LUV); at Enroute from KDI to CGK @2024-01-25 | ||||||||
| Batik Air Indonesia | KNKT recommends Batik Air Indonesia to develop detailed guidance and procedure for ensuring that the IM SAFE personal checklist can be used to assess pilot physical and mental condition properly | Batik Air revised the OM-A by adding detailed guidance for pilot and flight attendant (all crew members) to apply the IMSAFE personal checklist. The revision also described detailed procedures to use the checklist, which requires all crew members to use the IMSAFE personal checklist before performing a flight duty. After completing the self-assessment using the checklist, if the crew feels that they are not fit to fly, they can immediately report to the respective chief so they can be relieved from the flight duty. Batik Air conducted several efforts to ensure that the revised guidance and procedure are implemented properly, such as: issued safety notice to pilots and flight attendants, and recorded the recipient of the safety notice; conducted safety campaign within the company which highlighted the IMSAFE personal checklist not only to all crew members but also to all ground support personnel. | PK-LUV | Aturan | Closed | 2024 | ||
| Batik Air Indonesia | Therefore, KNKT recommends Batik Air Indonesia to develop detailed procedures to conduct cockpit check for ensuring that the cockpit check can be implemented properly. | Batik Air revised the Safety Emergency Procedures by adding detailed procedures to conduct periodic cockpit check. The periodic cockpit check must be conducted no more than every 30 minutes.In addition, Batik Air also conducted several efforts to ensure that the periodic cockpit check procedure is implemented properly, such as: issued safety notice to pilots and flight attendants which highlighted the revised periodic cockpit check procedure; conducted safety campaign within the company which highlighted the revised periodic cockpit check procedure; presented the revised periodic cockpit check procedure during monthly pilot and flight attendant sharing session. | PK-LUV | Aturan | Closed | 2024 | ||
| 2025 - Other, Batik Air Indonesia (Airbus A320/PK-LUV); at Enroute from KDI to CGK @2024-01-25 | ||||||||
| Batik Air Indonesia | Directorate General of Civil Aviation Advisory Circular (AC) 120-08 provided information and guidance for aircraft operators to develop and implement a fatigue management program. The investigation was unable to find any detailed guidance in the aircraft operator document that described the recommended quantity of sleep nor requirement for pilot to plan sleep ahead of time as mentioned in the AC 120-08. In addition, the investigation found that the pilot sleep during flight was most likely considered as common practice to deal with insufficient sleep time prior to the duty.The lack of detailed guidance from aircraft operator for pilot to have adequate sleep most likely has made the pilot did not utilize their scheduled rest period appropriately and might be managed by improper common practice by sleeping during flight.Therefore, KNKT recommends Batik Air Indonesia to develop and implement fatigue management to include recommended quantity of sleep and requirement for pilot to plan sleep ahead of time. | Batik Air Indonesia issued Preflight Rest Recommendation policy which had been socialized to all flight crew through Notice to Pilot (NTP) on 27 March 2025. The policy contained strategies for pilot to stay at their best performance during daytime flight and also nighttime flight including recommended rest time. The Preflight Rest Recommendation policy had been added to Operation Manual Part A (OM-A) Issued 05 Revision 1 with effective date of 1 April 2025. | Aturan | Closed | 2024 | |||
| 2024 - Controlled Flight into Terrain , Smart Cakrawala Aviation (Pilatus PC-6/PK-SNE); at 5Nm South East of Binuang Airport @2024-03-08 | ||||||||
| Smart Aviation | Smart Aviation Operation Manual Part A (OM-A) required pilots to be familiar with the area, route, and aerodrome prior to conducting the flight. The OM-A describes the area, route, and aerodrome information that can be found in the INDOAVIS Route Chart Manual, VFR Route Guidance, and Operations Manual Part C.The investigation was unable to find route guidance of a flight from Tarakan to Binuang provided by the aircraft operator. The absence of this guidance was not in accordance with the OM-A and was unable to ensure pilot having sufficient guidance to conduct flights from Tarakan to Binuang.Therefore, KNKT recommends Smart Aviation to develop and implement route guidance to conduct flights from Tarakan to Binuang. | Aturan | Open | 2024 | ||||
| 2024 - Runway Excursion, Trigana Air Service (ATR 42/PK-YSP); at Stevanus Rumbewas Airport, Serui Papua @2024-09-09 | ||||||||
| Trigana Air Service | When the pilot advanced both power levers to the notch, engine torque and NP increased as expected. After that, right engine torque continued increasing to a maximum of 116 percent, while left engine torque remained at 90 percent. At the same time, NP of the right engine dropped to 72 percent while NP of the left engine remained at 100 percent. The pilots did not notice the difference in torque and NP values between the two engines, until the aircraft speed about 100 knots. The takeoff procedure in the FCOM states that the FO must monitor the engine parameters. Failure to monitor the engine parameters during takeoff could lead to unidentified any engine abnormality. Therefore, KNKT recommends the Trigana Air Service to ensure the take-off procedure is carried out by all pilots. | Aturan | Open | 2024 | ||||
| 2024 - Controlled Flight into Terrain , Whitesky Aviation (Bell Helicopter 429/PK-WSW); at enroute to Kaorahai helipad, North Maluku @2024-02-20 | ||||||||
| The Indonesia Weda Bay Industrial Park | KNKT recommends IWIP to review the Aerodrome Manual and Aerodrome Emergency Plan of Weda Bay Airport to include the procedure of responsibility in managing helipads including the procedure of the emergency involving helicopter operation. | Pengawasan | Open | 2024 | ||||
| 2023 - Ground Collision, Lion Air (Boeing 737-900/PK-LFO); at Mopah Airport, Merauke @2023-01-26 | ||||||||
| Unit Pelaksana Bandar Udara Internasional Mopah, Merauke | The parking configuration at Mopah Airport was nose-in parking and all available markings/guidelines in the apron were suitable for aircraft to leave the aircraft stand utilizing towing tractor. However, all aircraft parked on the apron did not utilize towing tractor and the parking maneuver was conducted by self-maneuvering using aircraft own power.Considering that there was no turn bar, turning line, lead-out line nor alignment bar available in the apron which can be used for self-maneuvering parking, a safe aircraft maneuver cannot be ensured as pilot did not have any guidelines during the self-maneuver.Therefore, KNKT recommends the Airport Operation Unit of Mopah Airport in cooperation with aircraft operators to review the parking configuration to ensure safe maneuver when aircraft leave the aircraft stand. | Prasarana | Open | 2023 | ||||
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| Unit Pelaksana Bandar Udara Mopah, Merauke | The parking configuration at Mopah Airport was nose-in parking and all available markings/guidelines in the apron were suitable for aircraft to leave the aircraft stand utilizing towing tractor. However, all aircraft parked on the apron did not utilize towing tractor and the parking maneuver was conducted by self-maneuvering using aircraft own power.Considering that there was no turn bar, turning line, lead-out line nor alignment bar available in the apron which can be used for self-maneuvering parking, a safe aircraft maneuver cannot be ensured as pilot did not have any guidelines during the self-maneuver.Therefore, KNKT recommends the Airport Operation Unit of Mopah Airport in cooperation with aircraft operators to review the parking configuration to ensure safe maneuver when aircraft leave the aircraft stand. | Prasarana | Open | 2023 | ||||
| 2023 - Navigation Errors, Susi Air (Cessna C208B Caravan/PK-BVU); at Rokot Airport (WIEB) @2023-05-23 | ||||||||
| Rokot Airport Operator | On 30 May 2023, Rokot Airport operator submitted Notice to Airman Notice (NOTAM) which advised that there was work in progress on a new runway which located 228.6 meters from right side of threshold Runway 17. The NOTAM was published and effective from 30 May 2023 at 0700 UTC until 30 June 2023 at 1700 UTC. As the available closed runway markings had not been in accordance with the standard requirement mentioned in the DGCA Manual of Standard (MOS) Civil Aviation Safety Regulation (CASR) Part 139 and no other aeronautical publication that mentioned the existence of the Runway 14-32, the mentioned NOTAM had not been considered sufficient to ensure pilots are aware of the undesignated Runway 14-32 at Rokot.Therefore, KNKT recommends the Rokot Airport to review the NOTAM content and its duration to ensure that the notice could provide pilot awareness of an undesignated Runway 14-32 at Rokot. | Pengawasan | Open | 2023 | ||||
| Rokot Airport Operator | In 2019, the Airport Register for Rokot Airport was issued by the Directorate General of Civil Aviation (DGCA) and was valid until 11 November 2022. Until the day of the occurrence, the renewal process was not requested by the airport operator. The invalidity of the Airport Register may not ensure that the airport operation has met the standard requirement. Therefore, KNKT recommends the Rokot Airport operator to ensure the renewal process of Airport Register is completed before the due date. | Pengawasan | Open | 2023 | ||||