Lion Air Flight 904 Explained

Lion Air Flight 904
Image Upright:1.2
Occurrence Type:Accident
Summary:Crashed into the sea on approach; controlled flight into water; failed go-around attempt
Site:Off Ngurah Rai International Airport, Denpasar, Bali, Indonesia
Coordinates:-8.7492°N 115.1414°W
Plane1 Image:Lion Air Boeing 737-8GP; @CGK 2014 (14622211887).jpg
Plane1 Image Upright:1.2
Plane1 Caption:PK-LKU, the aircraft similar to the one involved
Aircraft Type:Boeing 737-8GP
Operator:Lion Air
Iata:JT904
Icao:LNI904
Callsign:LION INTER 904
Tail Number:PK-LKS
Origin:Husein Sastranegara International Airport, Bandung, Indonesia
Destination:Ngurah Rai International Airport, Denpasar, Indonesia
Occupants:108
Passengers:101
Crew:7
Fatalities:0
Injuries:46
Survivors:108

Lion Air Flight 904 was a scheduled domestic passenger flight from Husein Sastranegara International Airport in Bandung to Ngurah Rai International Airport in Bali, Indonesia. On April 13, 2013, the Boeing 737-800 operating the flight crashed into water short of the runway while on final approach to land. All 101 passengers and 7 crew on board survived the accident. At 3:10 pm, the aircraft crashed approximately 0.6nmi short of the seawall protecting the threshold of Runway 09. The aircraft's fuselage broke into two and 46 people were injured, 4 of them seriously.[1] [2]

Among the findings contained in the final investigation report was that the crew continued the approach in adverse weather conditions beyond the point at which the approved procedure would have required to abort the landing. The subsequent attempt to go around was made too late to avoid the impact with the sea. There were no issues with the aircraft and all systems were operating normally.

Background

Aircraft

The aircraft involved was a 53-day-old Boeing 737-8GP with serial number 38728 and registered as PK-LKS. It had logged about 142 hours and 37 minutes of flight time in 104 takeoff and landing cycles. It was manufactured by Boeing Commercial Airplanes on 19 February 2013 and was powered by two CFM International CFM56-7B24E engines.

Crew and passengers

The captain was 48-year-old Mahlup Gozali, an Indonesian national who joined Lion Air on 3 February 2003 and had logged 15,000 hours of flight experience, including 6,173 hours and 53 minutes on the Boeing 737.[3] His co-pilot was 24-year-old Chirag Kalra, an Indian national who had 1,200 flight hours, 923 of which were on the Boeing 737. He joined Lion Air on 25 April 2011.[4]

There were two pilots and 5 flight attendants with 101 passengers on board consisting of 95 adults, 5 children and 1 infant. 97 passengers were Indonesians, one French, one Belgian, and two Singaporeans. 6 of the crew were Indonesian while one came from India.[5]

Investigation

The Indonesian National Transportation Safety Committee (NTSC) published a preliminary report on 15 May 2013. Flight data showed that the aircraft continued to descend below the minimum descent altitude (MDA), which is 142m (466feet) above ground level (AGL). The report found that at 270m (890feet) AGL, the first officer reported that the runway was not in sight. At approximately 46m (151feet) AGL, the pilot again stated he could not see the runway. Flight data showed that the pilots attempted to perform a go-around at approximately 6m (20feet) AGL, but contacted the water surface moments later. The captain's go around decision came far too late. The bare minimum altitude for a 737 go around is, as of altitude is lost when executing the manoeuvre.[6] There has been no indication that the aircraft suffered any mechanical malfunction.[7] A final report was published in 2014.[8]

In January 2017, Budi Waseso, the chief of Indonesia's national narcotics agency, alleged that the pilot of Lion Air Flight 904 was under the influence of drugs at the time of the accident, and had hallucinated that the sea was part of the runway. That claim directly contradicted the statement made after the accident by Indonesia's transport ministry, which said the pilots had not tested positive for drugs.[9]

The NTSC concluded that the flight path became unstable below minimum descent altitude with the rate of descent exceeding 1000ft/min. Analysis of the pitch angle versus engine power based on the flight data recorder,[8] The flight crew lost situational awareness and visual references as the aircraft entered a rain cloud during the final approach below minimum descent altitude. The Captain's go-around decision and execution was conducted at an altitude which was insufficient for it to be executed successfully. The pilots were not provided with timely and accurate weather information considering the weather around the airport and particularly on final approach was changing rapidly.[8]

See also

Notes and References

  1. Web site: Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea . Simon . Hradecky . The Aviation Herald . 1 May 2013 . 9 May 2013.
  2. Web site: Haryanto. Arif. Kronologi Insiden Lion Air LNI 904 PK-LKS di Bandara Ngurah Rai. Chronology of Incident involving Lion Air LNI 904 PK-LKS at Ngurah Rai Airport. bot: unknown. https://web.archive.org/web/20140201163416/http://www.bumn.go.id/angkasapura1/publikasi/berita/kronologi-insiden-lion-air-lni-904-pk-lks-di-bandara-ngurah-rai/. 1 February 2014. 16 April 2013. Angkasa Pura Airports. id.
  3. News: 2013-04-13 . Lion Air Bantah Ghozali Lewati Batas Jam Kerja . Lion Air Denies Ghozali Has Exceeded Working Hours . dead . https://web.archive.org/web/20160305021747/http://www.metrotvnews.com/metronews/video/2013/04/13/6/175402/Lion-Air-Bantah-Ghozali-Lewati-Batas-Jam-Kerja . 2016-03-05 . 2020-08-26 . Metro TV . id.
  4. Web site: Firdaus . Fahmi . 2013-04-15 . Kecepatan Lion Air Capai 350 Km Jam . Lion Air Speed Reaches 350 Km Hours . live . https://web.archive.org/web/20130419142711/http://news.okezone.com/read/2013/04/15/337/791716/kecepatan-lion-air-capai-350-km-jam . 2013-04-19 . 2020-08-26 . nasional.okezone.com . id.
  5. Web site: MUSIBAH LION AIR: 4 Warga Negara Asing Jadi Korban. Henrykus F. Nuwa Wedo. 2013-04-15. Bisnis.com. https://web.archive.org/web/20181108050319/http://industri.bisnis.com/read/20130415/98/8719/musibah-lion-air-4-warga-negara-asing-jadi-korban. 2018-11-08. 2018-11-08.
  6. Web site: Final Report Lion Air Flight 904 – Pilot Error - Cockpit Chatter . 2 May 2015 . 1 June 2015 . https://web.archive.org/web/20150601164319/http://www.cockpitchatter.com/final-report-lion-air-flight-904-pilot-error/ . dead .
  7. Web site: Preliminary Report No. KNKT.13.04.09.04 . 14 May 2013 . National Transport Safety Committee . 21 November 2014 . dead . https://web.archive.org/web/20130810015121/http://www.skybrary.aero/bookshelf/books/2271.pdf . 10 August 2013 .
  8. Web site: Final Report No. KNKT.13.04.09.04, PT.Lion Mentari Airlines (Lion Air) Boeing 737 - 800;PK-LKS Ngurh Rai International Airport, Bali Republic of Indonesia 13 April 2013. dead. https://web.archive.org/web/20141129155932/http://asndata.aviation-safety.net/reports/Indonesia/20130413-0_B738_PK-LKS.pdf. 29 November 2014. 21 November 2014. National Transportation Safety Committee.
  9. News: Bali crash pilot 'hallucinated', says Indonesia anti-narcotics boss. 2017-01-15. Sydney Morning Herald. 2017-01-14.