KOMITE NASIONAL KESELAMATAN TRANSPORTASI

REPUBLIC OF INDONESIA

FINAL
KNKT.19.05.10.04
Aircraft Accident Investigation Report

PT. Batik Air Indonesia

Airbus A320; PK-LZJ
Sultan Hasanuddin International Airport
Republic of Indonesia
25 May 2019

2020
This Final Report was published by the Komite Nasional Keselamatan
Transportasi (KNKT), Transportation Building, 3rd Floor, Jalan Medan
Merdeka Timur No. 5 Jakarta 10110, Indonesia.
The report was based upon the investigation carried out by the KNKT in
accordance with Annex 13 to the Convention on International Civil
Aviation Organization, the Indonesian Aviation Act (UU No. 1/2009) and
Government Regulation (PP No. 62/2013).
Readers are advised that the KNKT investigates for the sole purpose of
enhancing aviation safety. Consequently, the KNKT reports are confined to
matters of safety significance and may be misleading if used for any other
purpose.
As the KNKT believes that safety information is of greatest value if it is
passed on for the use of others, readers are encouraged to copy or reprint
for further distribution, acknowledging the KNKT as the source.

When the KNKT makes recommendations as a result of its

investigations or research, safety is its primary consideration.
However, the KNKT fully recognizes that the implementation of
recommendations arising from its investigations will in some cases
incur a cost to the industry.
Readers should note that the information in KNKT reports and
recommendations is provided to promote aviation safety. In no case is
it intended to imply blame or liability.

Jakarta, August 2020

KOMITE NASIONAL
KESELAMATAN TRANSPORTASI
CHAIRMAN

SOERJANTO TJAHJONO
TABLE OF CONTENTS
TABLE OF CONTENTS ........................................................................................................i
TABLE OF FIGURES ......................................................................................................... iii
ABBREVIATIONS AND DEFINITIONS ..........................................................................iv
SYNOPSIS ............................................................................................................................... v
1 FACTUAL INFORMATION ......................................................................................... 1
1.1 History of the Flight............................................................................................... 1
1.2 Injuries to Persons.................................................................................................. 3
1.3 Damage to Aircraft ................................................................................................ 3
1.4 Other Damage ........................................................................................................ 3
1.5 Personnel Information ........................................................................................... 3
1.5.1 Pilot .......................................................................................................... 3
1.5.2 Air Traffic Controller ............................................................................... 3
1.5.3 Apron Movement Control Officer ............................................................ 4
1.5.4 Towing Tractor Driver ............................................................................. 4
1.5.5 Towing Tractor Driver Supervisor ........................................................... 4
1.5.6 Wing-man ................................................................................................. 4
1.5.7 Headset-man ............................................................................................. 5
1.6 Aircraft Information............................................................................................... 5
1.7 Meteorological Information ................................................................................... 6
1.8 Aids to Navigation ................................................................................................. 6
1.9 Communications .................................................................................................... 6
1.10 Aerodrome Information ......................................................................................... 6
1.10.1 Parking Stand B1 ...................................................................................... 8
1.10.2 Closed-Circuit Television......................................................................... 9
1.11 Flight Recorders................................................................................................... 11
1.12 Wreckage and Impact Information ...................................................................... 13
1.13 Medical and Pathological Information ................................................................ 15
1.14 Fire ....................................................................................................................... 15
1.15 Survival Aspects .................................................................................................. 15
1.16 Tests and Research .............................................................................................. 16
1.17 Organizational and Management Information ..................................................... 16
1.17.1 Aircraft Operator .................................................................................... 16

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 1.17.2 Ground Handling Service Provider ........................................................ 18
1.17.3 Aircraft Maintenance Provider ............................................................... 18
1.17.3.1 Engine Start Procedure.......................................................... 18
1.17.3.2 Pushback Procedure .............................................................. 19
1.17.3.3 Reporting Accident Procedure .............................................. 20
1.17.4 Airport Operator ..................................................................................... 22
1.17.5 Air Traffic Services Provider ................................................................. 23
1.17.6 Aerodrome Design Standards and Recommended Practices.................. 23
1.17.7 Accident within Indonesia Territory ...................................................... 24
1.18 Additional Information ........................................................................................ 25
1.18.1 Towing Tractor Information ................................................................... 25
1.18.2 Headset Tools ......................................................................................... 25
1.18.3 Human Performance ............................................................................... 26
1.19 Useful or Effective Investigation Techniques ..................................................... 26
2 ANALYSIS ..................................................................................................................... 27
2.1 Pushback Operation ............................................................................................. 27
2.2 Personnel Awareness ........................................................................................... 28
3 CONCLUSIONS ............................................................................................................ 30
3.1 Findings ............................................................................................................... 30
3.2 Contributing Factors ............................................................................................ 34
4 SAFETY ACTION ........................................................................................................ 35
4.1 Batik Air .............................................................................................................. 35
4.2 Batam Aero Technic ............................................................................................ 36
4.3 Angkasa Aviasi Servis ......................................................................................... 37
4.4 Angkasa Pura I Branch Office Sultan Hasanuddin International Airport ........... 38
5 SAFETY RECOMMENDATIONS ............................................................................. 39
5.1 Angkasa Aviasi Servis ......................................................................................... 39

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TABLE OF FIGURES
Figure 1: The common push back activity and the location of headset jack on typical Airbus
A320 ............................................................................................................................. 5
Figure 2: The apron layout ......................................................................................................... 7
Figure 3: Parking stand B1 layout .............................................................................................. 9
Figure 4: The blocked view of parking stand B1 CCTV .......................................................... 10
Figure 5: The aircraft as recorded by the ATS provider CCTV system ................................... 10
Figure 6: The zoomed-in view of the ATS provider CCTV display showed the headset-man
position during pushback ........................................................................................... 11
Figure 7: The relevant parameters of the FDR ......................................................................... 12
Figure 8: The view from CCTV, 4 seconds after the aircraft moved ....................................... 14
Figure 9: The position of the towing tractor and when the aircraft stopped after the accident 14
Figure 10: The illustration of the nosewheels movement during pushback maneuverer (red dot
line) ............................................................................................................................ 15
Figure 11: The hazard area during towing operation as describes in the Batik Air AMM for
Airbus A318/A319/A320/A321 ................................................................................. 20
Figure 12: The towing tractor ................................................................................................... 25
Figure 13: The headset used by the headset-man during the accident ..................................... 26

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ABBREVIATIONS AND DEFINITIONS
AAS : Angkasa Aviasi Servis
AMC : Apron Movement Control
AOC : Air Operator Certificate
ATS : Air Traffic Services
ATT : Aircraft Towing Tractor
CASR : Civil Aviation Safety Regulation
CB : Circuit Breaker
CVR : Cockpit Voice Recorder
DGCA : Directorate General of Civil Aviation
ERM : Eergency Response Manual
EWIS : Electrical Wiring Interconnection System
FDR : Flight Data Recorder
ICAO : International Civil Aviation Organization
KNKT : Komite Nasional Keselamatan Transportasi/National Transportation
Safety Committee
LMPM : Line Maintenance Procedure Manual
LT : Local Time
MATSC : Makassar Air Traffic Services Center
MEL : Minimum Equipment List
OCC : Operational Control Center
OM-part A : Operation Manual Part A
PIC : Pilot in Command
SIC : Second in Command
SSQ : Batik Air Safety, Security and Quality
UTC : Universal Time Coordinated
WI : Working Instruction

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SYNOPSIS
On 25 May 2019, an Airbus A320 aircraft registered PK-LZJ was being operated on a
scheduled passenger flight from Sultan Hasanuddin International Airport (WAAA), Makassar
to Mopah International Airport (WAKK), Merauke. On board the aircraft was two pilots, five
flight attendants and 82 passengers.
At 1842 UTC (0242 LT), on night time, the aircraft commenced pushback from stand B1. The
push back operation used towing tractor with the three crews consisted of towing tractor
driver, a wing-man and a headset-man who performed by an aircraft mechanic. There was no
briefing among the crew related to the pushback activity including the push back maneuver.
The towing tractor driver and wing-man used high visibility vest while the headset-man used
company uniform without any fluorescence strip or high visibility vest.
The push back maneuver did not follow the guideline and the headset-man walked behind the
nose wheel while observing the engine start process. During a turn, the aircraft nose wheel
passed over the right foot of the headset-man. The towing tractor driver felt a bump and
noticed that the headset-man laid on the ground. The headset-man evacuated to the nearest
hospital for medical treatment and found sustaining fracture on his right tarsometatarsal.
The investigation determined that the aircraft and towing tractor airworthiness serviceability,
and communication transmission were not an issue on this occurrence. Therefore, the analysis
discussed the pushback operation and personnel awareness. The investigation concluded the
contributing factors of the occurrence as follows:
The different assumption of pushback maneuver between headset-man and the push back
tractor driver, and both were fixated to their own duties while working on a reduced
alertness condition, resulted in the towing tractor driver did not aware of the headset-man
position and the headset-man did not aware of the nose wheel position. These conditions led
to the nose wheel passed over the headset-man foot.
The KNKT had been informed of safety actions taken by the involved parties resulting from
this occurrence. However, there still remain safety issues that need to be considered.
Therefore, the KNKT issues the following safety recommendations addressed to the Angkasa
Aviasi Servis.

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1 FACTUAL INFORMATION
1.1 History of the Flight
On 25 May 2019, an Airbus A320 aircraft registered PK-LZJ was being operated on
a scheduled passenger flight from Sultan Hasanuddin International Airport (WAAA),
Makassar to Mopah International Airport (WAKK), Merauke. On board the aircraft
were two pilots, five flight attendants and 82 passengers. The Pilot in Command
(PIC) acted as Pilot Flying and the Second in Command (SIC) acted as Pilot
Monitoring.
After the passenger boarding completed, the aircraft was ready for push back. The
SIC then requested push back clearance to the Makassar Tower controller.
At 1841 UTC (0241 LT 1 ) on early morning (night) time, the Makassar Tower
controller issued pushback clearance to the pilot to maneuver aircraft heading south
and to expect takeoff on runway 03. This heading south clearance was a simplify
term to communicate since the actual heading south clearance would be south west.
The SIC readback the clearance and the PIC relayed the instruction to the headset-
man using intercom. The headset-man then advised the towing tractor driver using
hand signal that the clearance was push back to heading south. Prior this pushback
operation, there was no briefing conducted to discuss the pushback maneuver
between the ground personnel.
At 0242 LT, the aircraft commenced pushback from stand B1 and the aircraft was on
heading north-westerly. The push back operation used towing tractor with the crew
consisted of towing tractor driver, a wing-man and a headset-man who performed by
a mechanic. During the pushback, the towing tractor head lights and rotating beacon
light located above the driver compartment and the aircraft anti-collision lights were
illuminated. The towing tractor driver and wing-man used high visibility vest while
the headset-man used company uniform without any fluorescence strip or high
visibility vest.
The towing tractor driver maneuvered the towing tractor straight along the yellow
line (straight lead-in line) with the wing-man was on the left side and the headset-
man was on the right side of the towing tractor driver. The towing tractor was left-
hand drive (the steering wheel on the left side).
A few meters after following the straight lead-in line, the towing tractor driver
maneuvered the towing tractor to the left and made the aircraft facing north. This
maneuver made the aircraft out of the straight lead-in line provided, with intention to
provide sufficient space when maneuvering aircraft to face south west (see figure 2
for the detail apron layout and figure 4 for the aircraft maneuver illustration).

1 The 24-hours clock in Local Time (LT) is used in this report to describe the time as specific events occured. Local time is
Universal Time Coordinated (UTC) +8 hours.

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During maneuvering, when the aircraft was facing north, the wing-man moved to the
right side of the towing tractor to observe the left wing and the tail of the aircraft to
ensure safe separation with an aircraft that was parked on parking stand 37. The
headset-man was on the right side of the towing tractor (on the left side of the
aircraft), and walking faced to the aircraft to observe the aircraft left engine starting
process after the right engine had been started without any abnormality.
After the aircraft faced to the north, the towing tractor driver continued by straight
maneuver then turned right with intention to make the aircraft facing south west.
During the turning maneuver to face south west, the towing tractor driver was
focusing on the aircraft movement as it was not a straight maneuver, and did not
recall the headset-man position. The aircraft nose wheel then rolled behind the
headset-man and passed over the right foot of the headset-man. The towing tractor
driver felt a bump and noticed that the headset-man laid on the ground. The towing
tractor driver stopped the towing tractor when the aircraft was facing west and the
aircraft nose wheel was facing north.
When the aircraft stopped, the PIC attempted to call the headset-man via intercom
and no answer. The wing-man which also noticed that the headset-man laid on the
ground, then ran to the ground handling service provider office to report the
occurrence and asked for medical assistance for the headset-man.
The engineer group leader on duty arrived to the occurrence site and took over the
duty of headset-man. The engineer group leader advised the PIC of the occurrence
and to shut down the right engine. The pilot then set the aircraft parking brakes and
shut down the engine. Thereafter, the PIC advised the engineer group leader to check
the aircraft condition.
The visual observation to the right foot of headset-man indicated that there was
possibility of bone fracture. The headset-man evacuated to the nearest hospital for
medical treatment using Batik Air operational car.
At 0244 LT, the SIC requested to the Makassar Tower controller to hold on present
position and advised that there was problem with the towing tractor, the request was
approved. After performed aircraft visual check and no damage found on the aircraft,
the engineer group leader suggested the PIC to continue the flight and was agreed.
The engineer group leader considered the occurrence was not mandatory occurrence
to be reported as there was no defect on the aircraft, and the pilots were not aware
that the occurrence was classified as accident.
The pilots restarted the engines, and at 0249 LT, the SIC advised to the Makassar
Tower controller that the aircraft was ready to continue the pushback and it was
approved. The towing tractor driver and wing-man continued the duty while the role
of the headset-man was replaced by the engineer group leader. The towing tractor
driver continued to maneuver by pushing further the aircraft until reach the taxiway
guideline.

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 At 0253 LT, after pushback completed, the SIC requested taxi clearance to the
Makassar Tower controller and was instructed to taxi to runway 03. The aircraft
taxied and departed using runway 03 at 0301 LT. The aircraft continued to fly and
arrived at the destination aerodrome uneventfully. After landed the PIC filed
occurrence report to the Batik Air Operation Department and the Safety, Security and
Quality (SSQ) Department. The Komite Nasional Keselamatan Transportasi (KNKT)
was notified of the occurrence by the Batik Air SSQ Department after the PK-LZJ
aircraft had departed from Makassar.
1.2 Injuries to Persons
Total in
Injuries Flight crew Passengers Others
Aircraft
Fatal - - - -
Serious - - - 1
Minor - - - Not applicable
None 7 82 89 Not applicable
TOTAL 7 82 89 1
The headset-man is Indonesian, sustained fracture on his right tarsometatarsal 2 .
After the accident, the headset-man evacuated to hospital and was hospitalized until
29 May 2019.

1.3 Damage to Aircraft

The aircraft was undamaged.
1.4 Other Damage
No other damage to property and/or the environment in this accident.
1.5 Personnel Information
1.5.1 Pilot
Both pilots are Indonesian and held valid license with qualification as Airbus A320
aircraft pilot. The PIC had valid first-class medical certificate with limitation to wear
lenses that correct for distant vision and possess glasses that correct for near vision.
The SIC had valid first-class medical certificate without any limitation.
The total flying hours of the PIC on Airbus A320 was 2,588 hours while the SIC was
3,840 hours.
1.5.2 Air Traffic Controller
The air traffic controller had valid license and rating to perform aerodrome control
service in Makassar Tower unit. The controller also had valid third-class medical
certificate without any limitation.

2 Tarsometatarsal is a joint composed of three arthrodial joints, the bones of which articulate with the bases of the
metatarsal bones.

3
1.5.3 Apron Movement Control Officer
The Apron Movement Control (AMC) officer is Indonesian, 33 years old, had valid
AMC license and 11 years of experience as AMC officer.
Prior the accident, the AMC officer never noticed any incident during pushback
maneuver nor pushback maneuver that did not follow the available guidance lines in
the parking stand B1.
1.5.4 Towing Tractor Driver
The towing tractor driver is Indonesian, 43 years old, had valid Ground Support
Equipment license and rating to drive Aircraft Towing Tractor (ATT). The towing
tractor driver had 7 years of experience as ATT driver.
One day before the accident, the towing tractor driver was on noon shift from 1500
to 2300 LT. At the day of the accident, the towing tractor driver arrived in the airport
about 2215 LT for night shift from 2300 to 0730 LT. Prior to the accident, the towing
tractor driver had performed duty for pushback two aircraft from parking stand other
than B1.
Based on the daily activity record, in the last one month, the towing tractor driver
had pushed back 15 aircraft from parking stand B1 to face south west direction,
without following the available lead-in lines. The towing tractor driver considered
that if the offset lead-in line was followed, the aircraft maneuver would be too close
to the service road and he had reported this issue to his supervisor. The towing
tractor driver also did not consider to follow the straight lead-in line, considering this
maneuver required longer time for the aircraft to reach the taxiway line on a position
ready for taxi following the taxi guide line.
All the pushbacks were conducted successfully without any complaint from his
supervisor, engineer nor AMC officer. Three aircraft including the accident aircraft
was pushed back at night time condition.
The towing tractor driver did not recall ever paired with the injured headset-man.
Based on the daily activity record, in the last one month, the day of the accident was
the first time for the towing tractor driver paired with the injured head-set man.
1.5.5 Towing Tractor Driver Supervisor
The supervisor is Indonesian, 46 years old and had 14 years of experience as towing
tractor driver. The supervisor described that the pushback maneuver from the parking
stand B1 for facing aircraft to south-west direction was often conducted similar with
the accident aircraft maneuver. The supervisor did not consider the maneuver
without following the available guidance lines as hazard since there was no incident
ever happened prior to this accident. Moreover, the supervisor did not recall any
requirement to follow available guidance lines during pushback on the Ground
Support Equipment Standard Operation Procedure (SOP).
1.5.6 Wing-man
The wing-man is Indonesian, 25 years old and had 7 months of experience as wing-
man. At the day of the accident, the wing-man was on night shift from 2300 to 0730
LT and the pushback of the accident aircraft was his first duty assignment of the day.

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1.5.7 Headset-man
The headset-man is Indonesian, 27 years old which qualified as aircraft mechanic.
The headset-man had 4 years of experience as aircraft mechanic. The duty as aircraft
mechanic is to check the aircraft serviceability and usually follows by duty as
headset-man.
On the last two days, the headset-man was on night shift from 1930 to 0730 LT. On
the accident day, at 2300 LT the headset-man performed daily check for the PK-LZJ
aircraft which then followed by pushback operation.
The headset-man had conducted several pushback operations to maneuver aircraft
facing south west from parking stand B1, and recalled that all of the pushback
conducted by following the straight lead-in line.
Based on the daily job assignment record, in the last one month, the headset-man
recorded twice conducting pushback operation from parking stand B1, including the
accident aircraft. The previous pushback from the parking stand B1 was conducted at
night by following the straight lead-in line and the towing car driver was not the
same person with the day of the accident. During the accident, the headset-man
assumed that the push back would be conducted following the straight lead-in line.

1.6 Aircraft Information

The PK-LZJ aircraft had valid Certificate of Airworthiness and Certificate of
Registration. There was no report or record of aircraft system malfunction during the
occurrence. The aircraft was operated within the weight and balance envelope.
The headset jack (connector) for headset-man to plug his headset was located in the
nose area of the aircraft (see figure 1).

Figure 1: The common push back activity and the location of headset jack on
typical Airbus A320

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1.7 Meteorological Information
The meteorological information was not issue in this accident. The time of the
accident was night time.
1.8 Aids to Navigation
The aids to navigation were not issue in this accident.

1.9 Communications
The communication between Makassar Tower controller and the pilot was recorded
by ground based automatic voice recording equipment. The audio record on the CVR
had overwritten as the aircraft continued the flight. The audio transmission recorded
in the ground based automatic voice recording was in good quality. The significant
excerpt of audio communication was as follows:
Time (LT) Communication
02:41:27 The Makassar Tower controller issued engine start and pushback
clearance heading south to the pilot and it was readback.
02:44:21 The pilot requested to the Makassar Tower controller to hold on
present position and advised that there was problem with the towing
tractor, the request was approved.
02:49:44 The pilot advised to the Makassar Tower controller that the aircraft
was ready to continue the pushback and it was approved.
02:53:03 The pilot requested taxi clearance to the Makassar Tower controller
and was instructed to taxi to runway 03.
02:53:16 The Makassar Tower controller provided departure route clearance to
the pilot, included the Secondary Surveillance Radar (SSR) code3 for
the flight.
02:58:29 The Makassar Tower controller instructed the pilot to continue lining
up runway 03.
03:00:00 The Makassar Tower controller issued takeoff clearance using runway
03 for the pilot.

1.10 Aerodrome Information

The Sultan Hasanuddin International Airport (WAAA) is operated by PT. Angkasa
Pura I (Angkasa Pura I) which had valid aerodrome certificate. The airport located in
Makassar, Indonesia on coordinate 05°03’39.00” S; 119°33’16.00” E.
The airport had two runways (03-21 and 13-31), 13 taxiways, three aprons (new, old
and cargo), and 37 parking stands. The airport layout can be seen on figure 2.

3 The Secondary Surveillance Radar (SSR) code is the number assigned to a particular multiple pulse reply signal
transmitted by a transponder which make the aircraft can be displayed in radar display.

6
Figure 2: The apron layout

7
1.10.1 Parking Stand B1
The parking stand B1 located on the most north-east side of the new apron in
conjunction of taxiway ECHO, at coordinate 05°04’31.66” S 119°32’54.51” E. The
parking stand B1 is nose-in aircraft parking stand which can be used for narrow body
aircraft including Airbus A320 aircraft. The aircraft parked on the parking stand B1
would face on heading 300° (north-west direction).
The parking stand B1 has two offset lead-in lines and one straight lead-in line. The
lead-in lines use for guidance during taxi in and also during pushback maneuver. The
left and right offset lead-in line mentions in this investigation report refers to the
position looking outside from the parking bay or the view of pushback tractor driver.
The right offset lead-in line could not be used for taxi in guidance, as there was no
taxi route from north east direction. The left offset lead-in line is used for aircraft
which taxi from taxiway FOXTROT (south-west direction). The straight lead-in line
is used for aircraft which taxied from taxiway ECHO (south-east direction).
Therefore, the designated number of parking stand B1 only painted on the left offset
nose-wheel lead-in line and straight lead-in line.
The left offset lead-in line can be used as pushback guidance for aircraft facing north
east, while the right offset lead-in line and straight lead-in line were provided as
pushback guidance for aircraft to face south-west direction. If the right offset lead-in
line would be used for pushback guidance, the aircraft maneuver will be too close to
the service road, and if the straight lead-in line would be used, the aircraft have to be
pushed straight back close to taxiway ECHO until the nose wheel can taxi following
the apron taxiway centerline marking.

8
 Figure 3: Parking stand B1 layout
1.10.2 Closed-Circuit Television
The airport operator utilized Closed-Circuit Television (CCTV) system to support
the airport operation service. Other than security purposes, several CCTV cameras
that were located on the apron can be utilized by the Apron Movement Control
(AMC) unit to monitor the aircraft movement.
The CCTV camera located on the parking stand B1 was unable to provide clear view
of the pushback maneuver as the view was blocked by the passenger boarding bridge
(figure 4).

9
 Figure 4: The blocked view of parking stand B1 CCTV
The Air Traffic Services (ATS) provider also utilized CCTV system for security
purposes. One of the CCTV cameras located outside the tower building facing to the
apron recorded the push back maneuver. Based on the CCTV record, throughout the
pushback maneuver, the headset-man position as such that the nose wheels were
behind him (figure 6).
The CCTV from the airport operator or ATS provider indicated that the apron was
provided with sufficient light.

Figure 5: The aircraft as recorded by the ATS provider CCTV system

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 Figure 6: The zoomed-in view of the ATS provider CCTV display showed the
headset-man position during pushback

1.11 Flight Recorders

The aircraft was equipped with a Cockpit Voice Recorder (CVR) and a Flight Data
Recorder (FDR). The recorded voice on the CVR had overwritten.
The FDR of the aircraft was L-3 FDR model with part number 2100-4245-00 and
serial number 001303540. The FDR was downloaded in the KNKT facility and
contained data of 1,064 parameters with approximately 95 hours of aircraft
operation, which was containing 40 flights including the accident flight.

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 Figure 7: The relevant parameters of the FDR
The significant parameters of the FDR were as follows:
1. 18:42:18 UTC (02:42:18 LT), the aircraft heading was 300°, the ground speed
increased from 0 (the aircraft started to move) and maintained to 1 knot for 30
seconds.
2. 02:42:22 LT, the aircraft heading increased from 300° to 301° and continuously
increased (aircraft was turning to the right) until 02:42:56 LT, the ground speed
maintained at 1 knot.
3. 02:42:43 LT, the aircraft heading increased from 316° to 317° (aircraft was
turning to the right), the ground speed maintained at 1 knot, the N1 Engine
number 2 (right engine) increased from 0 to 1 % and continuously increased.
4. 02:42:48 LT, the aircraft heading increased from 322° to 324° (aircraft was
turning to the right), the ground speed increased from 1 knot to 2 knots and
maintained for seven seconds, the N1 Engine number 2 increased from 3.1 % to
3.6 %.
5. 02:42:55 LT, the aircraft heading increased from 332° to 333° (aircraft was
turning to the right), the ground speed reduced from 2 knots to 1 knot and
maintained for 11 seconds, the N1 Engine number 2 increased from 7 % to 8 %.
6. 02:42:56 LT, the aircraft heading reached the highest value of 334° and
maintained for four seconds, the ground speed maintained at 1 knot, the N1
Engine number 2 increased from 8 to 9 %.

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 7. 02:43:00 LT, the aircraft heading reduced from 334° to 333° and continuously
reduced (aircraft was turning to the left), the ground speed maintained at 1 knot,
the N1 Engine number 2 increased from 11 to 12 %.
8. 02:43:06 LT, the aircraft heading reduced from 329° to 328° (aircraft was
turning to the left), the ground speed increased from 1 knot to 2 knots and
maintained for eight seconds, the N1 Engine number 2 increased from 16 to
18%.
9. 02:43:08 LT, the aircraft heading reduced from 326° to 324° (aircraft was
turning to the left), the ground speed maintained at 2 knots, the N1 Engine
number 2 increased from 18% to 19% and maintained.
10. 02:43:14 LT, the aircraft heading reduced from 311° to 309° (aircraft was
turning to the left), the ground speed reduced from 2 to 1 knot, the N1 Engine
number 2 maintained at 19%.
11. 02:43:15 LT, the aircraft heading reduced from 307° and maintained to 306°,
the ground speed reduced from 1 to 0 knots (the aircraft stopped), and the N1
number 2 (right engine) maintained at 19%.
12. 02:43:21 LT, the aircraft heading maintained at 306°, the ground speed
remained 0 knots, the N1 number 2 remained 19%, and the brake pedals angle
indicated an increasing value.
13. 02:43:24 LT, the parking brake indicated ON until 02:43:28 LT.
14. 02:43:29 LT, the parking brake indicated OFF until 02:44:20 LT.
15. 02:44:21 LT, the parking brake indicated ON.
16. 02:45:18 LT, the N1 Engine number 2 reduced from 19% to 17% and
continuously reduced until 0% at 02:46:33 LT.
17. 02:49:45 LT, the parking brake indicated OFF.
18. 02:49:48 LT, the aircraft heading reduced from 306° to 305° (aircraft was
turning to the left) and continuously reduced.
19. 02:49:55 LT, the ground speed increased from 0 and to 1 knot (the aircraft
started to move), the aircraft heading reduced from 302° to 300° (aircraft was
turning to the left).
1.12 Wreckage and Impact Information
During turning the aircraft from facing north east to south east, the nose wheel of the
aircraft passed over the headset-man right foot. The towing tractor driver felt a bump
and noticed that the headset-man laid on the ground.
After the bump, the towing tractor driver stopped the towing tractor and the aircraft
stopped by facing south east. The aircraft was undamaged.
The location of the blood spills on coordinate 5°4'32.86"S; 119°32'55.67"E, about 50
meters from the beginning of parking stand B1, was considered as the location when
the nose wheel passed over the headset-man right foot.

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 Figure 8: The view from CCTV, 4 seconds after the aircraft moved

Figure 9: The position of the towing tractor and when the aircraft stopped after
the accident

14
 Figure 10: The illustration of the nosewheels movement during pushback
maneuverer (red dot line)

1.13 Medical and Pathological Information

No medical or pathological investigations were conducted as a result of this accident.

1.14 Fire
No evidence of fire during the accident.
1.15 Survival Aspects
The towing tractor driver stopped the maneuver after felt a bump and noticed that the
headset-man laid on the ground. The wing-man then ran to the ground handling
service provider office to report the occurrence and asked medical treatment for the
headset-man. About four minutes later, the headset-man evacuated to the nearest
hospital for medical treatment using Batik Air operational car.

15
1.16 Tests and Research
No test and research are performed in relation to this investigation.

1.17 Organizational and Management Information

1.17.1 Aircraft Operator
The PK-LZJ aircraft is owned by SMBC Aviation Capital Limited, Ireland and
operated by PT. Batik Air Indonesia (Batik Air) that had valid Air Operator
Certificate (AOC) number 121-050. The Batik Air was operating several aircraft
types consisted of 43 Airbus A320-200, eight Boeing 737-800 and six Boeing 737-
900ER aircraft.
The Batik Air has Operation Manual Part A (OM-part A) which contains policy and
procedure approved by the Directorate General of Civil Aviation. The relevant
subchapter to the investigation was described as follows:
11.1.1 ACCIDENT
An accident is an occurrence associated with the operation of an aircraft which:
• the aircraft sustains damage or structural failure which:
- adversely affects the structural strength, performance or flight
characteristics of the aircraft; and
- would normally require major repair or replacement of the affected
component,
• except for engine failure or damage, when the damage is limited to the engine,
its cowlings or accessories; or for damage limited to propellers, wing tips,
antennas, tyres, brakes, fairings, small dents or puncture holes in the aircraft
skin: or
• person is fatally or seriously injured as a result of:
- being in the aircraft;
- direct contact with any part of the aircraft, including parts which have
become detached from the aircraft; or,
- direct exposure to jet blast,
Except when the injuries are from natural causes, self-inflicted or inflicted by
other persons, or when the injuries are to stowaways hiding outside the areas
normally available to the passengers and crew.
• The aircraft is missing or is completely inaccessible.
11.1.4 SERIOUS INJURIES
A serious injury is an injury which is sustained by a person in an accident and
which:
• Requires hospitalization for more than 48 hours, commencing within seven
days from the date the injury was received; or
• Results in a fracture of any bone (except simple fractures of fingers, toes or
nose); or
• Involves lacerations which cause severe hemorrhage, nerve, muscle or tendon
damage; or
• Involves injury to any internal organ; or

16
• Involves second or third degree burns, or any burns affecting more than 5 per
cent of the body surface; or
• Involves verified exposure to infectious substances or injurious radiation.
11.3 PROCEDURES IN CASE OF ACCIDENT, SERIOUS INCIDENT OR
OVERDUE AIRCRAFT REPORT
11.3.1 INITIAL / IMMEDIATE NOTIFICATION TO THE COMPANY
In the event of an accident or a serious incident, either airborne or on the
ground, the Pilot in Command or a crew member, if physically able, or any other
person will advise OCC by the quickest available means, that will in turn advise
SSQ Directorate.
In the case the OCC is aware of a BATIK AIR aircraft accident or a serious
incident or, has reasons to believe a BATIK AIR aircraft has been involved in an
accident, or in the case of an overdue aircraft report, the OCC will immediately
advise BATIK AIR SSQ Directorate by the quickest available means.
As soon as it is advised of the situation, SSQ Directorate will declare the
corresponding emergency phase and manage the situation in accordance with
procedures detailed in the BATIK AIR Emergency Response Manual (ERM).
11.3.3 PRESERVATION, PRODUCTION AND USE OF FDR AND CVR
Following an accident or a serious incident, the Company must attempt to
preserve all FDR and CVR data and make it available to the investigating
authority. In addition, BATIK AIR will ensure all operational manuals and
documents in force at the time of the accident / serious incident are collected and
preserved.
PIC shall secure the CVR after experiencing serious incidents or accidents by
pulling the CVR CB(s) on the ground after engine shutdown procedures
completed and in coordination with maintenance personnel.
Events required pilot to secure the CVR CB(s)
I. ACCIDENTS
Weather occurrences causing serious injury or fatality for person onboard the
aircraft.
II. SERIOUS INCIDENTS
a. Collisions not classified as accidents.
b. Events requiring the emergency use of oxygen by the flight crew
c. Aircraft structural failures or engine disintegrations, including
uncontained turbine engine failures, not classified as an accident.
d. Multiple malfunctions of one or more aircraft systems seriously affecting
the operation of the aircraft.
e. Flight crew incapacitation in flight
f. Fuel quantity level or distribution situations requiring the declaration of
an emergency by the pilot, such as insufficient fuel, fuel exhaustion, fuel
starvation, or inability to use all useable fuel on board
g. Runway incursion in which a collision is narrowly avoided.

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 11.4 REPORTABLE EVENTS
11.4.1 NOTIFICATION AND REPORTING OF ACCIDENTS AND SERIOUS
INCIDENTS
As soon as it is advised of an accident or serious incident (refer to paragraph
§11.3.1 “INITIAL NOTIFICATION” of this Chapter, the Company (SSQ
Directorate) must, in turn, immediately, and by the most suitable and quickest
means available, report to the Indonesian National Transportation Safety
Committee (NTSC) and the DGCA, as well as to the Authority of the State of
occurrence.
This immediate occurrence report must in all cases, be submitted within 24 hours
following the accident or serious incident.
1.17.2 Ground Handling Service Provider
The ground handling services for Batik Air flight operations were provided by PT.
Angkasa Aviasi Servis (AAS).
The AAS issued Ground Support Equipment Operational Standard Operation
Procedure (SOP) as guidance for AAS personnel, including procedure for towing
tractor driver and wing-man during pushback. The subchapter 5.1.1 of the SOP,
described the procedure for conducting pushback operation for aircraft, the procedure
did not contain requirement to follow available guidance lines nor any requirement to
conduct briefing or have discussion with headset-man regarding the planning
maneuver that will be conducted. The briefing is only required when performing
aircraft towing.
1.17.3 Aircraft Maintenance Provider
The aircraft maintenance service for Batik Air flight operations in Makassar are
provided by PT. Batam Aero Technic (BAT). The BAT is an approved maintenance
organization under Civil Aviation Safety Regulation (CASR) part 145 which had
valid approval number 145D-914. The capability list approved by the Directorate
General of Civil Aviation (DGCA) included the maintenance activities for all Batik
Air aircraft in the base maintenance and line maintenance activities.
The line maintenance activities included aircraft daily check and departure handling.
The aircraft departure handling includes pushback activity.
The BAT has Line Maintenance Procedure Manual (LMPM) which defines
procedure in compliance with the aviation authority requirements, company policies,
procedures and technical manuals to perform Line Maintenance activities to the
customers under the company Fleet Management Programs.
1.17.3.1 Engine Start Procedure
The BAT LMPM subchapter 5.3.2 described aircraft dispatch procedure which
include the engine start procedure as follows:
5.3.2.5 START THE ENGINES.
Engineer or mechanic shall:
1. Check that all anti-collision lights are working to warn the personnel that
engine starting is about to taking placed.
2. Ensure the fire extinguisher is available and at the right location & position
to the engine about to start.

18
 3. Keep close contact with PIC during the starting up procedures.
CAUTION:
1. Personnel, tools and equipment are not allowed in the engine intake and
blast areas during the starting procedure or while engines are running.
2. All personnel present during the engine starting should wear their protective
earring aid.
1.17.3.2 Pushback Procedure
The BAT LMPM subchapter 5.6.2.2 described procedures as follows:
5.6.2.2 DURING PUSH-BACK
1. Pushback speed during the whole operation shall not exceed 5 (five) km/hrs.
2. Engineer or mechanic shall communicate with flight crew by interphone or
visual signal and tractor driver/helper by visual signals and or verbal
instruction refer to LMPM 4.1 Ground Cockpit Communication.
3. Certifying/Engineer and tractor driver shall ensure that the center line of an
aircraft fuselage (not only nose wheels) is aligned with the guideline.
4. Complete the check of the surrounding area, the Engineer or mechanic shall
give all clear signals to the flight crew. The engineer or mechanic ensures
that the fire extinguisher is always available at stand during engine starting.
The Batik Air Aircraft Maintenance Manual (AMM) for Airbus
A318/A319/A320/A321 task 09-10-00-584-002-A described towing procedure by
nose landing gear from the front with a towbar. Those tasks include warning as
follows:
WARNING: OBEY THESE SAFETY PRECAUTIONS DURING MOVEMENT OF
THE AIRCRAFT (TOWING, PUSHBACK OR TAXIING). MAKE
SURE THAT:
‐ THE PATH OF THE AIRCRAFT IS CLEAR OF PERSONS,
EQUIPMENT AND OTHER OBSTACLES.
‐ NO PERSONS GO NEAR THE TOW TRACTOR, TOWBAR,
LANDING GEARS, ENGINE NACELLES OR BELOW THE
AIRCRAFT FUSELAGE.
‐ ONLY QUALIFIED PERSONS ARE ON THE TRACTOR AND
NO PERSONS SIT OR STAND ON THE TOWBAR.
‐ NO PERSONS GO NEAR THE AIRCRAFT BEFORE IT IS
FULLY STOPPED.
‐ THERE IS A RISK OF INJURY OR DEATH IF YOU DO NOT
OBEY THESE INSTRUCTIONS.

19
 The towing procedure on subtask 09-10-00-584-064-A described that during the
towing operations, while the aircraft moves, all persons must be at a minimum
distance of 3 meters or 10 feet from the wheels and the tractor. The hazard area
during towing operations were illustrated on the following figure:

Figure 11: The hazard area during towing operation as describes in the Batik Air
AMM for Airbus A318/A319/A320/A321

1.17.3.3 Reporting Accident Procedure

The BAT LMPM subchapter 7.2 described accident/incident report requirement as
follow:
7.2 ACCIDENT/INCIDENT REPORT
7.2.1 PURPOSE
This procedure is guidance for line maintenance personnel to report of any
incident / accident occurs in Batam Aero Technic customer fleet under the
contracted maintenance.

20
7.2.2 CRITERIA OF TECHNICAL INCIDENT OR REPORTABLE DEFECT
Generally in the conditions to be reported are those identified by individuals that
has resulted or may result in an unsafe condition that hazards seriously the flight
safety. Examples of occurrences considered as Technical Incidents / Reportable
Defects are listed below:
 Serious structural damage (for example: cracks, permanent deformation,
delamination, debonding, burning, excessive wear, or corrosion) found
during maintenance of the aircraft or component.
 Serious leakage or contamination of fluids (for example: hydraulic, fuel, oil,
gas or other fluids).
 Failure or malfunction of any part of an engine or power plant and/or
transmission resulting in any one or more of the following:
 Non-containment of components/debris;
 Failures of the engine mount structure.
 Significant malfunction of a safety-critical system or equipment including
emergency system or equipment during maintenance testing or failure to
activate these systems after maintenance.
 Incorrect assembly or installation of components of the aircraft found
during an inspection or test procedure not intended for that specific
purpose.
 Wrong assessment of a serious defect, or serious non-compliance with MEL
and
 Technical logbook procedures.
 Serious damage to Electrical Wiring Interconnection System (EWIS).
 Any defect in a life-controlled critical part causing retirement before
completion of its full life.
 The use of products, components or materials, from unknown, suspect
origin, or unserviceable critical components.
 Misleading, incorrect or insufficient applicable maintenance data or
procedures that could lead to significant maintenance errors, including
language issue.
 Incorrect control or application of aircraft maintenance limitations or
scheduled maintenance.
 Releasing an aircraft to service from maintenance in case of any non-
compliance which endangers the flight safety.
 Serious damage caused to an aircraft during maintenance activities due to
incorrect maintenance or use of inappropriate or unserviceable ground
support equipment that requires additional maintenance actions.
 Identified burning, melting, smoke, arcing, overheating or fire occurrences.
 Any occurrence where the human performance, including fatigue of
personnel, has directly contributed to or could have contributed to an
accident or a serious incident.

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  Significant malfunction, reliability issue, or recurrent recording quality
issue affecting a flight recorder system (such as a flight data recorder
system, a data link recording system or a cockpit voice recorder system) or
lack of information needed to ensure the serviceability of a flight recorder
system.
After the line maintenance personnel identified accident or incident had occurred, the
procedure to be followed was as follows:
7.2.3 PROCEDURE
1. Safety action: do not move the aircraft and wreckage from the place of
accident/ incident unless:
- It is already permitted by DGCA or local authority,
- It is helping people in serious injury or trap,
- It avoids aircraft to break down / create more damage,
- It is avoiding or reducing danger to people,
- It prevents from other accident/incident (air navigation, etc.).
Before moving the aircraft and wreckage, pictures shall be made or a sketch
hand marking shall be made around the aircraft on the land. The part that
cannot be taken a picture shall be noted. Be careful while moving the
aircraft break downs and care from adding trouble.
2. The engineer who handles the aircraft shall be responsible for reporting
immediately using Internal Occurrence report form (BT-QMF-042).
3. The report is to be acknowledged by the leader to MCC Duty Manager or
Line Maintenance Manager (or Deputy) and can be handed-over or sent by
e-mail.
4. Chief Line Station or Engineer in charge shall keep the copy of report in
file.
5. The report shall be either written or type written in block letters and in
English only.
6. Every incident / accident must be reported within 24 hours to Quality
Assurance Department and Safety & Security (SMS) Department, with copy
to Line Maintenance General Manager by MCC Duty Manager.
7. As necessary Quality Department and Safety Department may request
additional details.
8. Any further investigation shall be done under SMS Department authority.
NOTE: The aircraft records must be saved and do not change the record.
1.17.4 Airport Operator
The Sultan Hasanuddin International Airport is operated by PT. Angkasa Pura I
(Angkasa Pura I) which also operates 12 other airports in Indonesia. The Angkasa
Pura I had valid aerodrome certificate to operate airport services in Sultan
Hasanuddin International Airport.
The airport service provided by the airport operator included the apron movement
control, which conducted by Apron Movement Control (AMC) unit in coordination
with the Makassar Tower control unit.

22
 The AMC unit is responsible to monitor person and vehicle movement in the apron
while the clearance for aircraft movement is provided by the Makassar Tower unit.
The airport operator had Working Instruction (WI) number IK/UPG-OP/PU-01-07
which contained instruction to be followed by the AMC unit during monitoring of
pushback and start engine operation. The instruction number 6.8 described that
during pushback operation, the towing tractor driver must be accompanied by wing-
man and the aircraft must be pushed back following the guidance line until reach the
taxiway centerline.
The AMC unit utilized radio communication to monitor the communication between
pilot and tower controller, and several Closed-Circuit Television (CCTV) displays to
monitor the pushback operation.
During the pushback of PK-LZJ, the AMC officer did not maintain continuously
watch the pushback maneuver from the CCTV. The AMC officer was aware of the
problem related to the pushback process when he heard the communication between
pilot and the tower controller. The blocked view of the passenger boarding bridge
prevented the AMC officer to see clearly the current situation. About five minutes
later, the AMC officer heard the communication of the pilot requesting to continue
the pushback to the tower controller. Based on this communication, the AMC officer
assumed that the problem was daily technical reason that did not require assistance
from the AMC unit.
About 0530 LT, the AMC officer received the accident report from the airport
security.

1.17.5 Air Traffic Services Provider

The Perusahaan Umum Lembaga Penyelenggara Pelayanan Navigasi Penerbangan
Indonesia (AirNav Indonesia) is the Air Traffic Services (ATS) provider within
Indonesia. The ATS in Makassar is provided by AirNav Indonesia branch office
Makassar Air Traffic Services Center (MATSC) which held a valid Air Traffic
Services provider certificate.
The ATS provided by the MATSC were aerodrome control service; approach control
service; aeronautical communication service; and flight information services. The
aerodrome control service is provided by the Makassar Tower control unit which
includes providing taxi clearance to parking stand and pushback clearance from
parking stand. The Makassar Tower unit must coordinate with AMC unit for
assignment of the parking stand number.
1.17.6 Aerodrome Design Standards and Recommended Practices
International Civil Aviation Organization (ICAO) Document 9157 Part 4, provides
guidance for proper design and installation of visual aids used at airports. On the
subchapter 2.3.5 lead-in line as follows:
Lead-in lines
2.3.5 These lines provide guidance from apron taxiways into specific aircraft
stands…For nose-in stands, the lead-in lines will mark the stand centre line to
the aircraft stopping position. There will be no lead-out lines, and the tractor
drivers will use the lead-in lines for guidance during the push-back manoeuvre.

23
1.17.7 Accident within Indonesia Territory
According to the Aviation Law Number 1 of 2009 and Government Decree Number
62 of 2013 described that KNKT have responsibility to conduct investigation on
accident of civil aircraft occurred within the territory of Republic of Indonesia.
The CASR part 830 subpart 830.2 defines:
Accident. An occurrence associated with the operation of an aircraft in which,
in the case of a manned aircraft, takes place between the time any person boards
the aircraft with the intention of flight until such time as all such persons have
disembarked, or in the case of an unmanned aircraft, takes place between the
time the aircraft is ready to move with the purpose of flight until such time as it
comes to rest at the end of the flight and the primary propulsion system is shut
down, in which:
a. person is fatally or seriously injured as a result of:
1) being in the aircraft, or
2) direct contact with any part of the aircraft, including parts which have
become detached from the aircraft, or
3) direct exposure to jet blast,
except when the injuries are from natural causes, self-inflicted or inflicted by
other persons, or when the injuries are to stowaways hiding outside the areas
normally available to the passengers and crew; or.
b. the aircraft sustains damage or structural failure which:
1) adversely affects the structural strength, performance or flight
characteristics of the aircraft, and
2) would normally require major repair or replacement of the affected
component,
except for engine failure or damage, when the damage is limited to a single
engine (including its cowlings or accessories), to propellers, wing tips,
antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear
doors, windshield, the aircraft skin (such as small dents or puncture holes),
or for minor damages to main rotor blades, tail rotor blades, landing gear,
and those resulting from hail or bird strike (including holes in the radome);
c. or the aircraft is missing or is completely inaccessible.
Serious injury. An injury which is sustained by a person in an accident and
which:
a. requires hospitalization for more than 48 hours, commencing within seven
days from the date the injury was received; or
b. results in a fracture of any bone (except simple fractures of fingers, toes or
nose); or
c. involves lacerations which cause severe haemorrhage, nerve, muscle or
tendon damage; or
d. involves injury to any internal organ; or
e. involves second- or third-degree burns, or any burns affecting more than 5
per cent of the body surface; or
f. involves verified exposure to infectious substances or injurious radiation.

24
 Any accident or serious incident of civil aircraft occurred within Indonesia territory,
the CASR 830 subpart 830.06 requires person, organization or enterprise engaged in
or offering to engage in an aircraft operation, with minimum delay and by the most
suitable and quickest means available, must report to the Komite Nasional
Keselamatan Transportasi (KNKT).

1.18 Additional Information

1.18.1 Towing Tractor Information
The towing tractor manufactured by PT. United Tractors Pandu Engineering
(PATRiA), Indonesia and the model PTD 50 is capable to tow Airbus A320.
According to the product specification, the maximum speed for PTD 50 with
forward-1 clutch is 12 km/hour and forward-2 clutch is 32 km/hour. The steering
wheel of the PTD 50 is left hand drive which the steering wheel is on the left side.
Prior to the accident, there was no report or record of towing tractor system
malfunction.

Figure 12: The towing tractor

1.18.2 Headset Tools

The headset-man utilized wired headset manufactured by David Clark Company with
product code of ML0715-28. During the accident the headset cable was rolled up and
headset-man held the rolled-up cable. The total length the headset on rolled-up
condition was 6 meters, from the headset to rolled-up cable was about 1.5 meters
while from rolled-up to headset jack was about 4.5 meters. Prior to and during the
accident, there was no record or report of headset malfunction.

25
 Figure 13: The headset used by the headset-man during the accident
1.18.3 Human Performance
Human normally need 8 hours of sleep in a 24-hour period which losing as little as 2
hours of sleep will result in acute sleep loss, which will induce fatigue and degrade
subsequent waking performance and alertness (Dinges et al., 1996)4.
Human brain has a clock which regulates 24-hour pattern of body function which
controls the human sleep and wakefulness time 5 . According to FAA aeromedical
safety brochure6, circadian rhythm is described as described as an internal biological
clock that regulates our body functions, based on our wake/sleep. A circadian cycle
disruption can lead to acute sleep deficits, cumulative sleep loss, decreases in
performance and alertness, and various health problems.
According to the Dinges et al., (1996), on 24-hour cycle, between 0200 and 0600 is
estimation for window of circadian low, when human biological functions and
performance efficiency are at their lowest level. Maintaining wakefulness during the
window of circadian low has a higher potential for fatigue and increased requirement
for recovery.

1.19 Useful or Effective Investigation Techniques

The investigation was conducted in accordance with the KNKT approved policies
and procedures, and in accordance with the standards and recommended practices of
Annex 13 to the Chicago Convention.

4 Dinges et al. (1996). Principles and guidelines for duty and rest scheduling in commercial aviation. The article can be
found in https://ntrs.nasa.gov/search.jsp?R=19990063635.
5 National Sleep Foundation, (2018). The article can be found in https://sleepfoundation.org/sleep-topics/what-circadian-
rhythm.
6 FAA (2009). Circadian Rhythm Disruption and Flying. The article can be found in
https://www.faa.gov/pilots/safety/pilotsafetybrochures/.

26
2 ANALYSIS
Prior to the pushback, there was no record or report of the towing tractor and aircraft
system malfunction. The pilots and the headset-man described that during the
occurrence, there was no indication of a communication transmission problem. The
investigation determined that the aircraft and towing tractor airworthiness
serviceability, and communication transmission were not an issue on this occurrence.
Therefore, the analysis would discuss the relevant issues as follows:
 pushback operation; and
 personnel awareness.

2.1 Pushback Operation

The parking stand B1 was nose-in parking stand that had two offset lead-in lines and
one straight lead-in line. According to the International Civil Aviation Organization
(ICAO) Document 9157 Part 4, nose-in parking stand would not have lead-out lines
and the towing tractor driver would use the lead-in lines for guidance during the
push-back maneuver. Therefore, the parking stand B1 had the right offset lead-in line
and the straight lead-in line that can be used as pushback guidance for making
aircraft to face south-west direction.
The BAT LMPM required the certifying personnel or engineer, and tractor driver
must ensure that the centerline of nose wheels and aircraft fuselage is aligned with
the guideline. The airport operator Working Instruction also required the AMC unit
to ensure the aircraft was pushback following the guidance line until reach the
taxiway centerline. Those procedures indicated that the pushback must be conducted
following the available guidance lines.
The towing tractor driver did not consider to follow the available lines when pushed
back aircraft from parking stand B1 to face south west direction. He considered if the
straight lead-in line was followed, the maneuver would take a longer time as the
aircraft must be pushed back until the nose wheel could taxi following the apron
taxiway centerline marking, and if the right offset lead-in line was followed, the
aircraft maneuver would be too close to the service road.
In the last one month, the towing tractor driver had pushed back 15 aircraft from
parking stand B1 to face south west direction, without following the available lead-in
lines. All the pushbacks were conducted successfully without any complaint from his
supervisor, engineer nor AMC officer.
The towing tractor driver supervisor had been aware of the deviated maneuver. As
there was no incident ever happened prior to the accident nor requirement to follow
the available guidance lines in the GSE SOP, the supervisor did not consider the
deviated maneuver as a hazard. Similar with the supervisor, the successful pushback,
might have made the previous engineer paired with the towing tractor driver did not
consider the deviated maneuver as a hazard.

27
 The view to the parking stand B1 on the CCTV system that was blocked by the
passenger boarding bridge resulted in the pushback maneuver did not completely
visible by the AMC officer. This condition might have made the AMC officer never
noticed pushback maneuvers on the parking stand B1 that were not follow the
available guidance lines. Without any incident, the pushback maneuvers on the
parking stand B1 that were conducted deviating from the guideline was unnoticed.
The unnoticed AMC officer of the actual pushback maneuver and the successful
pushback experienced without any complaint from engineer nor towing tractor driver
supervisor resulted in the pushback of the accident aircraft had been conducted using
deviated pushback maneuver.

2.2 Personnel Awareness

The towing tractor driver had successfully pushed back 15 aircraft from parking
stand B1 without following the available straight lead-in line. During the accident,
the towing tractor driver intended to make the same maneuver. Meanwhile, the
headset-man had conducted several pushback operations to maneuver the aircraft
facing south west direction from parking stand B1 and all maneuvers followed the
available straight lead-in line. The headset-man assumed that the push back would be
conducted following the straight lead-in line.
The Ground Support Equipment Standard Operation Procedure (GSE SOP) did not
require towing tractor driver to conduct briefing related to the pushback maneuver,
among the personnel involved in the pushback activity. The briefing among the crew
including the push back maneuver was not performed prior to pushback commenced.
The absence of the briefing and different experiences resulted in difference
assumption of the pushback maneuver between the headset-man and the towing
tractor driver.
After the pushback initiated, the towing tractor driver initially turned the tractor to
the left, and made the aircraft turned to heading approximately 334°. This maneuver
made the aircraft deviated from the lead-in straight line. The towing tractor driver
then turned the tractor to the right. During this turning maneuver, the tractor driver
focused on the aircraft maneuver as it was not a straight maneuver, and assumed that
the headset-man would know the deviated maneuver. The towing tractor driver did
not recall the headset-man position until the headset-man laid on the ground.
During the pushback, the headset-man was wearing company uniform without
fluorescence strip uniform or high visibility vest. Those condition might reduce the
headset-man for being visible by the towing tractor driver.
The pushback operation was conducted during window of circadian low on night
time condition with sufficient light. Maintaining wakefulness during window of
circadian low might create fatigue that decreases human alertness and increase
requirement for recovery.
The different assumption of pushback maneuver, fixated to the aircraft maneuver,
decreasing visual to the headset-man on a reduced alertness condition, resulted in the
towing tractor driver did not aware of the headset-man position and continued the
maneuver until the accident happened.

28
Throughout the pushback maneuver, the headset-man position as such that the nose
wheels were behind him. This position made the headset-man did not have visual to
the nose wheel position and movement. The headset-man might have visual cues
when the aircraft fuselage deviated from the guide line or by referring the distance
between fuselage to headset-man that became closer, as the apron was provided with
sufficient light.
One day before the accident, the headset-man had worked on night shift, which
might have created fatigue and increased requirement for recovery. On the day of the
accident, the headset-man performed another night shift which might have created
higher potential for fatigue that reduce the alertness. This decreasing alertness might
affect the ability of headset-man to perform his duty during pushback including to
assess the visual cues to predict the actual pushback maneuver.
The Batik Air Aircraft Maintenance Manual (AMM) for Airbus
A318/A319/A320/A321 described hazard area during towing operation, which
required all person must be at a minimum distance of 3 meters from the wheels and
the tractor when the aircraft moved.
The headset cable was rolled with remaining length of about 4.5 meters from
headset-man to the headset jack. This created limited distance and movement
between the headset-man to the nose wheel as the headset jack was located in the
nose area of the aircraft.
The FDR data recorded that after 25 seconds the aircraft moved, the aircraft right
engine was started. The headset-man who walked on the right side of the towing
tractor (on the left side of the aircraft), faced to the left toward the right engine to
observe the engine starting process. This might make the headset-man walked too
close to the aircraft fuselage, and entering the hazard area in order to get better view
of the right engine. After the right engine starting process completed, the aircraft
stopped. This indicated that the accident happened during the transition of aircraft
right to left engine starting process while the headset-man was focusing to observe
the process.
The assumption that the pushback would follow the straight lead-in line, unable to
monitor the wheel position, limited distance to nose wheel, and fixated on observing
the aircraft engine starting process resulted in the headset-man did not aware the
position which entered the hazardous area. The decreasing awareness of the headset-
man that affected the ability to perform his duty during pushback including to assess
the visual cues to predict the actual pushback maneuver.
The different assumption of pushback maneuver, fixated to their own duties on a
reduced alertness condition, resulted in the towing tractor driver did not aware of the
headset-man position and the headset-man did not aware of the nose wheel position.
These conditions led to the nose wheel passed over the headset-man foot.

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3 CONCLUSIONS
3.1 Findings
Findings are statements of all significant conditions, events or circumstances in the
accident sequence. The findings are significant steps in the accident sequence, but
they are not always causal, or indicate deficiencies. Some findings point out the
conditions that pre-existed the accident sequence, but they are usually essential to the
understanding of the occurrence, usually in chronological order.
In this occurrence, the KNKT identified several findings as follows:
1. The pilots had valid licenses which qualified as Airbus A320 pilot and valid
first-class medical certificates.
2. The air traffic controller had valid license and rating to perform aerodrome
control service in Makassar Tower unit. The controller also had valid third-class
medical certificate.
3. The Apron Movement Control (AMC) officer had valid AMC license and 11
years of experience as AMC officer. Prior the accident, the AMC officer never
noticed any incident during pushback maneuver nor pushback maneuver that did
not follow the available guidance lines in the parking stand B1.
4. The towing tractor driver had valid Ground Support Equipment license and
rating to drive Aircraft Towing Tractor. The towing tractor driver had 7 years of
experience as Aircraft Towing Tractor driver.
5. The towing tractor driver supervisor had 14 years of experience as towing tractor
driver. The supervisor did not consider the maneuver without following the
available guidance lines as hazard since there was no incident ever happened
prior to the accident.
6. The headset-man has qualification as aircraft mechanic and had 4 years
experienced. The duty as aircraft mechanic usually follows by duty as headset-
man.
7. Prior to the pushback, there was no record or report of the towing tractor and
aircraft system malfunction. The pilots and the headset-man described that
during the occurrence, there was no indication of a communication transmission
problem. The investigation determined that the aircraft and towing tractor
airworthiness serviceability, and communication transmission were not an issue
on this occurrence.
8. According to the International Civil Aviation Organization (ICAO) Document
9157 Part 4, nose-in parking stand would not have lead-out lines and the towing
tractor driver would use the lead-in lines for guidance during the push-back
maneuver.
9. The parking stand B1 was nose-in parking stand that had two offset lead-in lines
and one straight lead-in line. Therefore, the parking stand B1 had the right offset
lead-in line and the straight lead-in line that can be used as pushback guidance
for making aircraft to face south-west direction.

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10. The BAT LMPM required the certifying personnel or engineer, and tractor driver
must ensure that the centerline of nose wheels and aircraft fuselage is aligned
with the guideline. The airport operator Working Instruction also required the
AMC unit to ensure the aircraft was pushback following the guidance line until
reach the taxiway centerline. Those procedures indicated that the pushback must
be conducted following the available guidance lines.
11. Based on the daily activity record, in the last one month, the towing tractor
driver had pushed back 15 aircraft from parking stand B1 to face south west
direction, without following the available lead-in lines. All the pushbacks were
conducted successfully without any complaint from his supervisor, engineer nor
AMC officer.
12. The towing tractor driver considered if the straight lead-in line was followed, the
towing tractor would take a longer time, and if the offset lead-in line was
followed, the aircraft maneuver would be too close to the service road.
13. The towing tractor driver supervisor had been aware of the deviated maneuver.
As there was no incident ever happened prior to the accident nor requirement to
follow the available guidance lines in the GSE SOP, the supervisor did not
consider the deviated maneuver as a hazard. Similar with the supervisor, the
successful pushback, might have made the previous engineer paired with the
towing tractor driver did not consider the deviated maneuver as a hazard.
14. The view to the parking stand B1 on the CCTV system that was blocked by the
passenger boarding bridge resulted in the pushback maneuver did not completely
visible by the AMC officer. This condition might have made the AMC officer
never noticed pushback maneuvers on the parking stand B1 that were not follow
the available guidance lines. Without any incident, the pushback maneuvers on
the parking stand B1 that were conducted deviating from the guideline was
unnoticed.
15. The unnoticed AMC officer of the actual pushback maneuver and the successful
pushback experienced without any complaint from engineer nor towing tractor
driver supervisor resulted in the pushback of the accident aircraft had been
conducted using deviated pushback maneuver.
16. During the accident, the towing tractor driver intended to make the deviated
maneuver. Meanwhile, the headset-man had conducted several pushback
operations to maneuver the aircraft facing south west direction from parking
stand B1 and all maneuvers followed the available straight lead-in line. The
headset-man assumed that the push back would be conducted following the
straight lead-in line.
17. The Ground Support Equipment Standard Operation Procedure (GSE SOP) did
not require towing tractor driver to conduct briefing related to the pushback
maneuver, among the personnel involved in the pushback activity. The briefing
among the crew including the push back maneuver was not performed prior to
pushback commenced. The absence of the briefing and different experiences
resulted in difference assumption of the pushback maneuver between the
headset-man and the towing tractor driver.

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18. The towing tractor driver maneuvered the towing tractor to follow the straight
lead-in line, and a few meters later made maneuver to the left in order to turn the
aircraft facing north. This maneuver deviated the aircraft from the available
straight lead-in line with intention to maneuver aircraft to face south west.
19. During this turning maneuver, the tractor driver focused on the aircraft maneuver
as it was not a straight maneuver, and assumed that the headset-man would know
the deviated maneuver. The towing tractor driver did not recall the headset-man
position until the headset-man laid on the ground.
20. During the pushback, the headset-man was wearing company uniform without
fluorescence strip uniform or high visibility vest. Those condition might reduce
the headset-man for being visible by the towing tractor driver.
21. The pushback operation was conducted during window of circadian low on night
time condition with sufficient light. Maintaining wakefulness during window of
circadian low might create fatigue that decreases human alertness and increase
requirement for recovery.
22. The different assumption of pushback maneuver, fixated to the aircraft
maneuver, decreasing visual to the headset-man on a reduced alertness condition,
resulted in the towing tractor driver did not aware of the headset-man position
and continued the maneuver until the accident happened.
23. Throughout the pushback maneuver, the headset-man position as such that the
nose wheels were behind him. This position made the headset-man did not have
visual to the nose wheel position and movement.
24. The headset-man might have visual cues when the aircraft fuselage deviated
from the guide line or by referring the distance between fuselage to headset-man
that became closer, as the apron was provided with sufficient light.
25. One day before the accident, the headset-man had worked on night shift, and on
the day of the accident, the headset-man performed another night shift which
might have created higher potential for fatigue that reduce the alertness. This
decreasing alertness might affect the ability of headset-man to perform his duty
during pushback including to assess the visual cues to predict the actual
pushback maneuver.
26. The Batik Air Aircraft Maintenance Manual (AMM) for Airbus
A318/A319/A320/A321 described hazard area during towing operation, which
required all person must be at a minimum distance of 3 meters from the wheels
and the tractor when the aircraft moved.
27. The headset cable was rolled with remaining length of about 4.5 meters from
headset-man to the headset jack. This created limited distance and movement
between the headset-man to the nose wheel as the headset jack was located in the
nose area of the aircraft.
28. The headset-man who walked on the right side of the towing tractor (on the left
side of the aircraft), faced to the left toward the right engine to observe the
engine starting process. This might make the headset-man walked too close to
the aircraft fuselage, and entering the hazard area in order to get better view of
the right engine.

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29. After the right engine starting process completed, the aircraft stopped. This
indicated that the accident happened during the transition of aircraft right to left
engine starting process while the headset-man was focusing to observe the
process.
30. The location of the blood spills on coordinate 5°4'32.86"S; 119°32'55.67"E,
about 50 meters from the beginning of parking stand B1 was considered as the
location when the nose wheel passed over the right headset-man foot.
31. The assumption that the pushback would follow the straight lead-in line, unable
to monitor the wheel position, limited distance to nose wheel, and fixated on
observing the aircraft engine starting process resulted in the headset-man did not
aware the position which entered the hazardous area.
32. The decreasing awareness of the headset-man that affected the ability to perform
his duty during pushback including to assess the visual cues to predict the actual
pushback maneuver.
33. The different assumption of pushback maneuver between headset-man and the
push back tractor driver, and both were fixated to their own duties while working
on a reduced alertness condition, resulted in the towing tractor driver did not
aware of the headset-man position and the headset-man did not aware of the nose
wheel position. These conditions led to the nose wheel passed over the headset-
man foot.
34. The hospital observation indicated that the headset-man sustained fracture on his
right tarsometatarsal. The headset-man was hospitalized for three days.
35. The engineer group leader on duty took over the duty of headset-man. The
engineer group leader advised the PIC of the occurrence and to shut down the
right engine. The pilot then set the aircraft parking brakes and shut down the
engine. Thereafter, the PIC advised the engineer group leader to check the
aircraft condition.
36. After performed aircraft visual check and no damage found on the aircraft, the
engineer group leader suggested the PIC to continue the flight and was agreed.
The engineer group leader considered the occurrence was not mandatory
occurrence to be reported as there was no defect on the aircraft, and the pilots
were not aware that the occurrence was classified as accident.
37. The aircraft continued to fly and arrived at the destination aerodrome
uneventfully. After landed the PIC filed occurrence report to the Batik Air
Operation Department and the Safety, Security and Quality (SSQ) Department.
The Komite Nasional Keselamatan Transportasi (KNKT) was notified of the
occurrence by the SSQ Department after the PK-LZJ aircraft had departed from
Makassar.
38. The Flight Data Recorder (FDR) recorded the occurrence while the recorded
voice communication on the Cockpit Voice Recorder (CVR) had overwritten.
39. According to the Civil Aviation Safety Regulation part 830 subpart 830.2 and
Batik Air OM-part A, the PK-LZJ occurrence is classified as accident which
must be reported to the KNKT with minimum delay and by the most suitable and
quickest means available.

33
 40. The Batik Air OM-part A subchapter 11.3.1 described in the event of an
accident, either airborne or on the ground, PIC or a crew member if physically
able or any other person will advise the OCC by the quickest means available
that will in turn advise the SSQ Directorate.
41. The Batik Air OM-part A subchapter 11.3.3 described following accident or a
serious incident, the company must attempt to preserve all FDR and CVR data
and make it available to the investigation authority. The PIC shall secure CVR
after experiencing accident or serious incident by pulling the CVR CB(s) on the
ground after engine shutdown procedures completed and in coordination with
maintenance personnel. However, the accident which require PIC to pull the
CVR CB(s) was only when any person experiences serious or fatal injury due to
weather encounters.
42. The BAT LMPM subchapter 7.2 described occurrence criteria of
accident/incident as a condition which has resulted or may resulted in an unsafe
condition that seriously affected the flight safety. The manual provided example
of accident/incident to be reported which only referred to technical incident or
defect problem.

3.2 Contributing Factors

Contributing factors is defined as actions, omissions, events, conditions, or a
combination thereof, which, if eliminated, avoided or absent, would have reduced the
probability of the accident or incident occurring, or mitigated the severity of the
consequences of the accident or incident.
The identification of contributing factors does not imply the assignment of fault or
the determination of administrative, civil or criminal liability. The presentation of the
contributing factors is based on chronological order and not to show the degree of
contribution.
The KNKT concluded the contributing factors as follows:
The different assumption of pushback maneuver between headset-man and the push
back tractor driver, and both were fixated to their own duties while working on a
reduced alertness condition, resulted in the towing tractor driver did not aware of the
headset-man position and the headset-man did not aware of the nose wheel position.
These conditions led to the nose wheel passed over the headset-man foot.

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4 SAFETY ACTION
At the time of issuing this Report, the KNKT had been informed of safety actions
taken by the related parties resulting from this occurrence.
4.1 Batik Air
On 19 June 2019, the Batik Air published safety notice number
005/SSQ/SN/VI/2019. The notice was intended for pilot, flight attendant, line
maintenance, flight operation officer and Integrated Operation Control Center
(IOCC) officer with subject to ensure safety communication in regards with incident
or accident could be performed appropriately.
The notice highlighted an occurrence which resulted in injury due to direct contact
with any aircraft part as an example of abnormal situation that may categorized as
accident. The detail of safety notice can be found in the appendix of this report.
The Batik Air also had conducted corrective action to address the KNKT safety
recommendation in the Preliminary Report as follows:
04.L-2019-10.1
According to the Civil Aviation Safety Regulation part 830 subpart 830.2 and
Batik Air OM-part A subchapter 11.1, the PK-LZJ occurrence is classified as
accident which must be reported to the KNKT with minimum delay and by the
most suitable and quickest means available. As the occurrence was not reported
to the KNKT, the PK-LZJ aircraft continued the flight to the destination
aerodrome which made the CVR was overwritten.
The Batik Air OM-part A subchapter 11.3.3 described following accident or a
serious incident, the company must attempt to preserve all FDR and CVR data
and make it available to the investigation authority. The PIC shall secure CVR
after experiencing accident or serious incident by pulling the CVR CB(s) on the
ground after engine shutdown procedures completed and in coordination with
maintenance personnel. However, the accident which requires PIC to pull the
CVR CB(s) was only listed when any person experiences serious or fatal injury
due to weather encounters.
Therefore, the KNKT recommend the Batik Air to review and amend procedure to
enable CVR data can be preserved for investigation following accident and
serious incident.
Responding to the safety recommendation, the Batik Air had amended the OM-part
A subchapter 11.3.3 with detail description of event that requires pilot to secure the
CVR, and issued safety notice for pilot, flight attendant, engineer, line maintenance,
flight operation officer which highlighted the requirement to secure CVR on the new
subchapter 11.3.3.

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4.2 Batam Aero Technic
On 3 June 2019, the Batam Aero Technic published safety notice for engineer, line
maintenance, and training department which highlighted the hazard zone during
pushback.
On 22 July 2019, the Batam Aero Technic amended the Line Maintenance Procedure
Manual to include requirement for engineer, headset-man or wingman to have
coordination with the pushback car driver prior pushback operation.
On 30 June 2020, the Batam Aero Technic issued Fatigue Risk Manual (FRM) to
implement a fatigue risk and duty time management within the company.
The Batam Aero Techic also had conducted corrective action to address the KNKT
safety recommendation in the Preliminary Report as follows:
 04.L-2019-10.2
According to the Civil Aviation Safety Regulation part 830 subpart 830.2, the PK-
LZJ occurrence is classified as accident which must be reported to the KNKT
with minimum delay and by the most suitable and quickest means available. As
the occurrence was not reported to the KNKT, the PK-LZJ aircraft continued the
flight to the destination aerodrome which made the CVR was overwritten.
The BAT LMPM subchapter 7.2 described occurrence criteria of
accident/incident as a condition which has resulted or may resulted in an unsafe
condition that seriously affected the flight safety. The manual provided example
of accident/incident to be reported which only referred to technical incident or
defect problem.
The engineer group leader suggested the PIC to continue the flight as there was
no damage found in the aircraft and it was agreed. The engineer group leader
considered the occurrence was not mandatory occurrence to be reported as there
was no defect on the aircraft.
Therefore, the KNKT recommend the Batam Aero Technic to review and amend
procedures to enable accident or serious incident can be reported to the KNKT
without delay.
Responding to the safety recommendation:
 On 27 September 2019 the Batam Aero Technic issued safety notice for
engineer, line maintenance, and flight operation officer which highlighted the
event that need to be reported to KNKT as soon as possible.
 On 6 February 2020, the Batam Aero Technic revised the Emergency Response
Manual to include requirement to report accident and serious incident
immediately with the minimum delay and by the most suitable and quickest
means available to the aircraft operator when the occurrence occurs within
Batam Aero Technic area of operations.
 On 19 June 2020, the Batam Aero Technic revised the BAT LMPM to include
the definition of accident and serious incident which must be reported to the
KNKT with minimum delay and by the most suitable and quickest means
available.

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  04.L-2019-10.3
The pushback was conducted at night time. During the pushback, the towing
tractor driver and wing-man used high visibility vest while the headset-man used
company uniform without any fluorescence strip or high visibility vest. The
absence of fluorescence strip uniform or high visibility vest on personnel who
working on aircraft movement area during night time or reduced visibility
condition became hazard as those personnel might not be visible to other person.
Therefore, the KNKT recommend the Batam Aero Technic to ensure all personnel
working in the aircraft movement area is equipped with fluorescence strip
uniform or high visibility vest, especially during night time or reduced visibility
condition.
Responding to the safety recommendation, the Batam Aero Technic had issued
safety notice to all personnel to use personal protective equipment including the high
visibility vest while working.

4.3 Angkasa Aviasi Servis

On 3 June 2019, published safety notice to all Ground Support Equipment (GSE)
personnel, which highlighted hazard zone during pushback.
The Angkasa Aviasi Servis also had conducted corrective action to address the
KNKT safety recommendation in the Preliminary Report as follows:
04.L-2019-10.4
The pushback maneuver of the aircraft was not following the offset lead-in line
which provided to maneuver aircraft for facing south west. The towing tractor
driver considered that if the offset lead-in line was followed, the aircraft
maneuver would be too close to the service road. However, there was straight
lead-in line could be used as guidance during the pushback maneuver.
Since there was no requirement for briefing the wing-man and headset-man, the
maneuver of towing tractor driver deviate from guidance line during pushback
would only be known by the towing tractor driver. The deviation may make wing-
man and headset-man are unaware of the maneuver.
Therefore, the KNKT recommend the Angkasa Aviasi Servis to ensure towing
tractor drivers follow the available guidance line and/or conduct briefing for any
plan of deviation maneuver from the guidance line.
Responding to the safety recommendation, the Angkasa Aviasi Servis had amended
the Ground Support Equipment Operation SOP subchapter 5.1.1 and 5.1.2 which
required to conduct briefing among ground personnel regarding to the pushback
maneuver in every pushback operation, and also developed a Mini Briefing Form
that must be referred during the briefing.

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4.4 Angkasa Pura I Branch Office Sultan Hasanuddin International
Airport
On 10 December 2019, the Angkasa Pura I Branch Office Sultan Hasanuddin
International Airport conducted safety meeting with all aircraft operator and ground
handling service provider. The topic of the discussions included reminder for the
ground handling service provider follow the available lines during pushback
operation.
On 24 June 2020, the Angkasa Pura I issued safety notice to all branch offices which
highlighted the safety issue of pushback maneuver without following the available
guidance lines, and blocked CCTV view to the parking stand that might make AMC
officer was unable to notice pushback maneuvers that were conducted deviate from
the guideline. The safety notice also instructed the branch offices to mitigate those
highlighted safety issues, included several actions as follows:
1. Ensuring the readiness and reliability of the apron, guidance lines, CCTV and
airside lightings; and
2. Improving the surveillance of the aircraft movement, including pushback,
towing and taxi operation.

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5 SAFETY RECOMMENDATIONS
The KNKT acknowledged the safety actions taken by the direct involved parties,
however, there still remain safety issues that need to be considered. Therefore, the
KNKT issues the following safety recommendations addressed to the Angkasa
Aviasi Servis.

5.1 Angkasa Aviasi Servis

04.L-2019-10.7
According to the Dinges et al., (1996), on 24-hour cycle, between 0200 and 0600 is
estimation for window of circadian low, when human biological functions and
performance efficiency are at their lowest level. Maintaining wakefulness during the
window of circadian low has a higher potential for fatigue and increased requirement
for recovery.
The pushback operation was conducted during window of circadian low on night
time condition which might create fatigue that decreases human alertness and
increase requirement for recovery.
The reduced alertness combined with the different assumption of pushback
maneuver, focused attention to the aircraft maneuver, decreasing visual condition,
resulted in the towing tractor driver did not aware of the headset-man position and
continued the maneuver until the accident happened.
Therefore, the KNKT recommends the Angkasa Aviasi Servis to consider
establishing fatigue risk management.

39