Mandala Airlines Flight 091
Boeing 737-230 Adv · Stalled and crashed shortly after take-off due to improper configuration and lack of crew resource management
From Soewondo Air Force Base (MES) to Soekarno-Hatta International Airport (CGK)
Event
- NTSB case
- DCA05RA096
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Unknown · led by another country; figures from NTSB notifications
- Event fatalities
- 149 · all aircraft and ground
- Ground fatalities
- 49
- Occupants
- 117
- Survivors
- 17
- InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
- 43 · 26 on the ground
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- Airline
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Not recorded
Boeing 737-230 Adv
- Flight
- RI091
- Aircraft type
- Boeing 737
- Category
- Airplane · from aircraft type
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- PK-RIM
- Operator
- Mandala Airlines
- Onboard fatalities
- 100
- Route
- From Soewondo Air Force Base (MES)To Soekarno-Hatta International Airport (CGK)
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Non-U.S., Commercial
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Not recorded
- Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Not recorded
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Not recorded
Cause areas
- Personnel issues › Task performance
- Aircraft › Aircraft oper/perf/capability
- Aircraft › Aircraft systems
From the investigation findings the Wikipedia article reports, sorted into the NTSB's cause areas with AI assistance.
Approximate · Coordinates from the Wikipedia article; not checked against an investigation report.
From the Wikipedia article
Mandala Airlines Flight 091 (RI091/MDL091) was a scheduled domestic passenger flight from Medan to Jakarta, operated by Mandala Airlines with a Boeing 737-200. On 5 September 2005 at 10:15 a.m. WIB (UTC+7), the aircraft stalled and crashed into a heavily populated residential area seconds after taking off from Polonia International Airport. Of the 117 passengers and crew on board, only 17 survived. An additional 49 civilians on the ground were killed, making a total of 149 fatalities.
The crash of Flight 091 was a shock to North Sumatrans as the leader of North Sumatra province, Governor Rizal Nurdin, and his predecessor, Raja Inal Siregar, were among the passengers and both were killed in the crash.
The Indonesian National Transportation Safety Committee (NTSC) concluded that the crash was caused by the actions of the flight crew, in that they did not configure the aircraft properly for take-off. The retracted flaps and slats resulted in the aircraft being unable to fly due to insufficient lift. The aircraft take-off warning was not heard and investigators stated that it was possible the pilots did not receive a warning about the improper configuration, and were therefore unaware of their erroneous actions.
Flight
Flight 091 was a scheduled domestic passenger flight from Polonia International Airport (now Soewondo Air Force Base) in Medan, the largest city in Sumatra, to Soekarno-Hatta International Airport in the Indonesian capital Jakarta. Flight 091 was the second trip of the day for the aircraft, which had earlier flown from Jakarta to Medan with the same flight crew. The aircraft was pushed back at 09:52 a.m. and start-up clearance was given immediately after. It then taxied out onto Runway 23 and was cleared to take off at 10:03 a.m. with an altitude of 1,500 ft.
Accident
Flight crews then added thrust and the aircraft began rolling on the runway. As it was rolling, some passengers noted that the aircraft took longer than usual to take off from the airport, even though the aircraft was already in a nose up position. The aircraft briefly took off, then veered to the left and to the right, stalled and then the tail impacted the runway. As the tail struck the runway, it left marks on Runway 23.
The aircraft then struck several approach lights located at the end of the runway before traveling across grass, crossing a small river and finally crashing onto the crowded Djamin Ginting road. Onlookers and motorists on the road panicked as the aircraft came towards them. The left wing struck a building and the aircraft exploded into flames. It broke into three parts. Passengers on the aft fuselage stated that the front part of the aircraft was obliterated as the aircraft exploded. It continued to slide onto the road, hitting multiple cars, bikes, powerlines and streetlamps and destroying several shops and houses. Several unaware drivers got their vehicles flipped by the sliding aircraft and subsequently burst into flames. The aft fuselage then came to rest in the middle of the road.
Investigation and cause
Investigation
The investigation was carried out by the Indonesian National Transportation Safety Committee (NTSC), with assistance from the United States National Transportation Safety Board (NTSB) and representatives from Boeing as the manufacturer of the aircraft. The NTSC had also requested the Australian and the Thai authorities for a readout on the black boxes. According to a member of the NTSC, Rita Wijaya, the investigation could take up to one year. She promised that the final report on the crash would be made public.
Both flight recorders were recovered immediately after the crash and were sent to the United States for a readout by the NTSB. Even though both recorders were found in good condition, the NTSC noted that there was a malfunction on the cockpit area microphone (CAM). As such, investigators could not determine the actual situation inside the cockpit due to the poor quality of the cockpit voice recorder data.
According to investigators, since Flight 091 had difficulties in taking-off, investigators decided to investigate three main possible causes; the weight and balance of the aircraft, the condition of the engines, and the configuration of the flaps and slats.
Conclusion
The official final report on the accident was published by the National Transportation Safety Committee (NTSC) of Indonesia on 1 January 2009. According to the report, the probable causes of the accident were the following:
The aircraft took off with an improper take-off configuration, namely with retracted flaps and slats causing the aircraft failed to lift off.
Improper checklist procedure execution had led to failure to identify the flap in retract position.
The aircraft's take-off warning system horn was not heard on the CAM channel of the CVR. It is possible that the take-off configuration warning was not sounding.
The report also criticised the lack of coordination among the rescuers, which possibly could have caused the deaths of people who had survived the crash earlier as rescuers did not arrive in time. For example, during the crash the airport fire brigade decided to dispatch a limited number of fire fighting units to the crash site after considering that the crash was located outside of the airport area. The other firefighting units were told to remain in place, despite the airport being closed. Additional lack of infrastructure led to confusion among the rescuers to locate the crash site, thus hampering the search and rescue effort.
The NTSC issued several recommendations to Mandala Airlines and the Indonesian Directorate General of Civil Aviation (DGCA). One of these was a request for the DGCA to mandate airports in Indonesia to conduct a real-time exercise of their Airport Emergency Plan at least once a year.
Text from the Wikipedia article “Mandala Airlines Flight 091” (revision 1373417649, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article
Sources
Wikipedia article: Mandala Airlines Flight 091
- Article
- Mandala Airlines Flight 091
- Revision
- 1373417649 · 2026-09-05 · retrieved 2026-09-18
- Wikidata
- Q746785
- Licence
- Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
NTSB record DCA05RA096
- Event ID
- 20050916X01483
- Case number
- DCA05RA096
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Where each value comes from
- Record
- Wikipedia article "Mandala Airlines Flight 091" (page 2617879, revision 1373417649); merged with NTSB case DCA05RA096 (events / aircraft)
- Date
- Wikipedia infobox: date
- Place and country
- Wikipedia infobox: site
- Map position
- Wikipedia: Wikipedia article coordinates
- Aircraft, operator and route
- Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports); gaps and aircraft details from NTSB record DCA05RA096
- Operation
- airline flight number in the infobox
- Fatalities
- Reviewed (2026-09-19): NTSC final report KNKT/05.24/09.01.38, sec. 1.2 Injuries to Persons, https://www.faa.gov/sites/faa.gov/files/2022-11/Final_Report_Mandala_PK-RIM%205Sep05.pdf
- Ground fatalities
- Reviewed (2026-09-19): NTSC final report KNKT/05.24/09.01.38, sec. 1.2 Injuries to Persons, https://www.faa.gov/sites/faa.gov/files/2022-11/Final_Report_Mandala_PK-RIM%205Sep05.pdf
- Summary
- Wikipedia infobox: summary
Source notes (3)
- One occurrence in two sources, merged: the Wikipedia article "Mandala Airlines Flight 091" and NTSB case DCA05RA096, matched by the same aircraft registration and date. For this event outside the United States Wikipedia's values are used where the two differ; each value names its source.
- Death toll settled: the NTSB record (DCA05RA096) gives 145 and the Wikipedia article 149; NTSC final report KNKT/05.24/09.01.38, sec. 1.2 Injuries to Persons gives 149. NTSC table: fatal 5 crew + 95 passengers + 49 others = 149; ASN agrees (100 + 49). The NTSB figure of 145 matches no category and looks like an early or wrong ground count in the notification.
- No bulk values were replaced by the NTSB case API.