Final Report Lion Air Flight 904 – Pilot Error

The final report into the crash of a Lion Air Boeing 737-800 aircraft on short finals to land at Denpasar’s Ngurah Rai International airport on 13 April 2013 has identified several safety issues around the skill of the pilots and the carrier’s emergency response procedures.

The National Transportation Safety Committee (NTSC) report retains the same chronology as the preliminary report issued in May 2013. As with the earlier report, it highlights the failure of the captain and first officer to communicate effectively prior to impacting the water. The final report also refers to CCTV footage, which shows the extent of the rainy weather immediately prior to the crash, which prevented the flight crew from seeing the runway.

The first officer, who was flying, mentioned that the runway was not in sight as the aircraft descended through 900ft on final approach after an uneventful flight from Bandung. Although the aircraft’s automated systems issued a “minimum” warning at 550ft, the crew disengaged the autopilot and autothrottle, and continued the descent flying manually.

At 300ft, the report reveals that the cockpit voice recorder picked up a sound consistent with rain hitting the windshield, although there was no sound of windshield wipers. When the 737 had descended to just 150ft, the captain took control of the aircraft, while the first officer again said that he could not see the runway.
During interviews, the captain maintained that he was confident the runway would appear at any moment. It was only when the enhanced ground proximity warning system called a 20ft height alert that the pilot commanded a go-around but, just 1s later, the aircraft impacted the water. Though there were no fatalaties among the 101 passenges and seven crew, four passengers suffered serious injuries. The aircraft, bearing registration PK-LKS, was a complete hull loss.

“The (pilot in command’s) expectation that he would be able to see the runway after the rain can be considered as inability to accurately perceive what was going on in the flight deck and outside the aircraft, including the thunderstorm formation that was observed at an aircraft altitude below 900ft. This might be due to unutilised resources available in the flight deck and the limited visibility due to the hazy conditions which made the pilot unable to see the thunderstorm formation properly.”

The report makes it clear that the captain’s go around decision came far too late. It notes that the bare minimum altitude for a 737 go around is 50 feet, as 30 feet of altitude are lost when executing the manoeuvre. The manoeuvre also demands three seconds to executive effectively.

After the aircraft came to rest in the water, the report shows that the crew handled the evacuation poorly. The first officer initally attempted to evacuate passengers through the right cockpit window. When this proved unviable, he conducted the evacuation through the right-hand service door.
Meanwhile, a flight attendant on the left side of the aircraft was unable to detach a life raft from the aircraft, as her only training for this exercise consisted of watching a video.

The report lists 13 recommendations for five parties including Lion Air, airport operator PT Angkasa Pura I, and the Directorate General of Civil Aviation.
The key recommendations, however, focus on ensuring the pilots employ effective crew resource management skills, hand flying skills, and emergency procedures.

Lionair, this time…the cows

A Lionair Boeing 738, with 110 passengers and 7 crew on board, hit several cows on landing at the Indonesian Gorontalo airport. 

The incident occurred last Tuesday 6th at 21:11 LT (13:11Z)  when a Lionair Boeing 737-800 hit a number of cows after landing in dark conditions, the aircraft came to a stop past the runway end with a cow killed under the main gear.  No injuries were reported among the passengers and crew, the aircraft sustained minor damage.

The aircraft landed in good weather and visibility conditions, after touch down the crew noticed three cows on the runway, tried to steer the aircraft around them however hit the cows nonetheless, which resulted in the failure of brakes. The aircraft came to a stop about 10 meters past the paved surface of the runway end safety area.

The Ministry of Transport has given no explanation as to why the cows were on the runway.

Photo Credits:  The Guardian

Capt. Ivan

Lion Air looks to accelerate international expansion, starting with Thailand

Lion Air has embarked on the first phase of an aggressive international strategy which is starting to see the fast-growing airline group diversify away from its roots in the Indonesian domestic market. The Mar-2013 launch of an affiliate in Malaysia, Malindo Air, is expected to be followed by joint ventures in other Asian markets, starting with Thailand. A low cost, but hybrid operator, Lion over time will also look to grow its now tiny international network from its home market of Indonesia.

Internationalization with a focus on Southeast Asia is the right strategy for Lion as it cannot continue to rely almost entirely on the Indonesian domestic market. Indonesia has emerged as one of the world’s largest and fastest growing emerging markets. But with nearly 600 aircraft on order Lion needs to hedge its bets and not limit its growth to Indonesia, particularly given the threat that growing infrastructure constraints could lead to slower growth over the medium to long-term.

Lion, however, faces huge challenges as it starts to dip its paw in other markets. Establishing a strong brand and distribution network outside Indonesia will be Lion’s biggest challenge. Competition in any new market Lion enters will be fierce as it will not have the first low cost mover advantage it had in Indonesia. Pan-Asian low cost airline groups like AirAsia, Jetstar and, to a lesser extent, Tiger, already occupy the high ground.

Thailand already has two strong well-established LCCs in Thai AirAsia and Thai Airways affiliate Nok Air. Both are expanding rapidly, using proceeds from initial public offerings. Both also have strong local brands and distribution networks – something Lion has in Indonesia but could struggle to replicate in Thailand.

There is also a third, much smaller LCC in Thailand in the one-off Orient Thai. The unusual carrier, operating a mixture of 747s, 767s, 737s and MD-80s, made a push in the LCC sector several years ago with One-Two-Go, which ultimately failed, suggesting the difficulty in trying to establish a third major LCC player in the Thai market.

Orient Thai closed the One-Two-Go operation in 2008 and has since continued to have an LCC operation domestically under the Orient Thai brand while operating under more of a leisure/charter carrier model on international routes. But over the last couple of years Orient Thai has steadily cut back its domestic operation, using 737s in single class configuration; the reason: intense competition.

The Orient Thai domestic network currently consists of only two routes and four daily flights. The carrier has cut domestic capacity by a further 56% over the last year and now has just a 2% share of the domestic market, according to CAPA and Innovata data.

Nok domestic capacity is up about 45% compared to Jun-2012 levels, accounting for a 26% share of Thailand’s domestic market. Thai AirAsia, which has grown capacity by 26% year over year, currently has a 27% share of seat capacity.

Read full story and analysis at: CAPA – Centre of Aviation

Lion Air Bali Crash Report Highlights Pilot Training

Investigators have raised questions over training and cockpit procedures at Indonesian budget carrier Lion Air after a preliminary report into a crash last month off Bali found the captain was not at the controls at a “critical time”.

The National Transportation Safety Committee said in a report that Lion Air should immediately review or reinforce a number of safety measures related to landing procedures carried out by pilots.

However, it did not say how it had arrived at the preliminary conclusions from a sample of evidence compiled from “black box” flight data and cockpit voice recordings.

All 108 passengers and crew survived when the passenger jet undershot the tourist island’s main airport runway and belly-flopped into the water.

The report, released late on Tuesday, did not give an exact cause of the crash, but ruled out any major problems with the almost brand-new Boeing 737-800 passenger jet.

Weather reports indicated that there was a sudden loss of visibility in the area, it said, adding the first officer was in charge seconds before the plane crashed into the sea just before the runway.

Lion Air’s co-founder Rusdi Kirana said he would respect the outcome of the investigation, but voiced dismay at the interim recommendations which were directed solely at the airline.

“If our pilots make mistakes we are not scared to admit it, but we are not happy just blaming the pilots without proof,” he told Reuters.

“It is important not to give people the impression that we don’t have proper procedures. We take safety seriously, we are a profitable airline and we are not going to limit our budget on training and maintenance.”

The cause of the crash has potential implications for the reputation of one of the world’s fastest-growing airlines, which is fighting to be removed from a European Union safety blacklist.

Indonesia has also failed ICAO standards for aircraft operations and maintenance, and as a result American regulators have imposed restrictions on them starting or increasing flights to the United States.


The preliminary report said that the 24-year-old first officer, who had 1,200 hours of flying experience, was in control during the descent into the airport and reported that he could not see the runway 900 feet above ground.

The captain switched off the auto-pilot and the first officer handed over controls to him at 150 feet – or 1 minute, 6 seconds before the crash – after saying he again could not see the runway.

One second before the crash and with 20 feet separating the aircraft and the water, the pilot commanded a “go-around” and attempted to abort the landing, but the plane hit the water.

The report recommended Lion Air “review the policy and procedures regarding the risk associated with changeover of control at critical altitudes or critical time”.

It added the fast-growing airline should also “ensure the pilots are properly trained” on this subject.

The airline said standard aviation practice allowed pilots to change control at any time at the crew’s discretion.

It defended its standard procedures for aborting a landing and said these had last been reviewed in March last year.

A person familiar with the matter told Reuters last month that the pilot had described how he felt the 737-800 being “dragged” down by wind while he struggled to regain control.

The NTSC report said that the navigational aids and approach guidance facilities such as the runway lights at Bali’s Ngurah Rai Airport were all “functioning properly” at the time of the crash.

It did not address whether these facilities should include an Instrument Landing System (ILS).

Industry experts say such a feature is common at airports worldwide to help pilots keep to the right descent path. Bali does not have an ILS for planes landing from the West.

The report also did not address whether the jet may have been subject to wind shear or dangerous gusts of wind. Airport officials have told Reuters some of the airports at Asia’s best known holiday spots do not have wind shear detectors.

The NTSC said it expected to release its final report within the next 12 months.


Source:  Airwise

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