Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea
Last Update: September 1, 2014 / 14:17:28 GMT/Zulu time
Incident Facts
Date of incident
Apr 13, 2013
Classification
Accident
Airline
Lion Air
Aircraft Registration
PK-LKS
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
The investigation analysed that there were no issues with the aircraft and all systems operated normally.
With respect to the vertical profile the NTSC analysed that during the descent at about 600 feet AGL there was a wind shift initially increasing the aircraft's airspeed and deviations from the selected flight trajectory. About 20 seconds later, at 486 feet AGL, the autopilot was disconnected and the rate of descent increased to above 1000 fpm, at 30 feet AGL the rate of descent was 1136 fpm, the engines' thrust was set between 41 and 45 percent N1 during final approach and the pitch angle varied between 1.1 degrees nose down to 1.8 degrees nose up, just prior to impact the attitude was 1.6 degrees nose down while according to the FCOM the attitude should be between 0.0 and 0.5 degrees nose up and N1 between 58 and 61%.
With respect to the lateral profile the NTSC stated: "... that the flight from minimum descent altitude (MDA) still following the VOR approach lateral configuration (091°), rather than lining up to the runway lateral orientation (087°). The four degrees difference was never corrected by the flying pilot."
With respect to the flight crew appreciating the external environment the NTSC stated: "At an aircraft altitude of approximately 900 feet AGL, the SIC commented that the runway was not in sight whereas the PIC commented that he could see the approach light and commanded to continue the approach. From the interview, the PIC stated that he saw a flashing light at the beginning of runway 09 which was also observed by the SIC later on. During interview, the Ngurah Rai Tower controller stated that during that period, there was no runway lighting system illuminated other than the Precision Approach and Path Indicator (PAPI) lights."
The NTSC analysed that at about 300 feet AGL the sounds of rain on the windshield were recorded by the cockpit voice recorder, however, there were no sounds of the windshield wipers operating. The NTSC stated: "At about 900 feet, the PIC noticed that there was dark area on the short final meanwhile the flashing light was still visible. Based on this information, the PIC predicted that the dark area was narrow and the runway would be visible after a short time. This was an incorrect assessment of the weather conditions at the time. After the aircraft entered the rain, the runway was not visible until the aircraft impacted the water. The PIC’s expectation that the runway would become visible in the near future did not occur. The PIC may not have been aware of the thunderstorm characteristics, especially the mature state of cumulonimbus. The conditions stated above can be concluded as inadequate situational awareness."
The NTSC analysed with respect to crew resource management: "a series of errors occurred during approach, among other thing such as the absence of callouts, lack of monitoring and crosschecking both lateral and vertical path especially below MDA combined with the additional factor of adverse weather conditions at low altitude, were potentially more dangerous as time to make decision was short and the consequences of these events possibly catastrophic; however these errors were not corrected timely by the flight crew in accordance with operator’s CRM principles in managing threat and error."
The airline performed two immediate safety actions following the accident. 4 additional safety recommendations to the airline, two to the airport, two to meteorological services, one to AirNav Indonesia and five to Indonesia's Directorate of Civil Aviation were issued as result of the investigation.
Incident Facts
Date of incident
Apr 13, 2013
Classification
Accident
Airline
Lion Air
Aircraft Registration
PK-LKS
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
This article is published under license from Avherald.com. © of text by Avherald.com.
Article source
You can read 2 more free articles without a subscription.
Subscribe now and continue reading without any limits!
Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.
Send tip
Support AeroInside by sending a small tip amount.
Related articles
Lion B738 at Jakarta on Oct 26th 2022, engine trouble
A Lion Air Boeing 737-800, registration PK-LKK performing flight JT-330 from Jakarta to Palembang (Indonesia) with 169 passengers and 6 crew, was…
Lion B738 at Surabaya on May 18th 2022, bird strike
A Lion Air Boeing 737-900, registration PK-LHR performing flight JT-800 from Surabaya to Makassar (Indonesia) with 222 passengers and 7 crew, was…
Lion B739 at Padang on Dec 13th 2021, cabin did not properly pressurize
A Lionair Boeing 737-900, registration PK-LQR performing flight JT-145 from Padang to Batam (Indonesia) with 196 passengers and 7 crew, was climbing…
Lion B739 at Bandar Lampung on Dec 20th 2020, runway excursion during backtrack
A Lionair Boeing 737-900, registration PK-LGP performing flight JT-173 from Batam to Bandar Lampung (Indonesia) with 125 passengers and 7 crew, had…
Lion A333 at Kuala Namu on Sep 15th 2020, temporary runway excursion on landing
A Lion Air Airbus A330-300, registration PK-LEG performing flight JT-208 from Jakarta to Kuala Namu (Indonesia), landed on Kuala Namu's runway 23 in…
Newest articles
Delta A339 at New York on Apr 21st 2024, nose wheel steering fault
A Delta Airlines Airbus A330-900, registration N404DX performing flight DL-49 from Amsterdam (Netherlands) to New York JFK,NY (USA) with 295 people…
Condor A320 near Lausanne on Apr 21st 2024, hydraulic problem
A Condor Airbus A320-200, registration D-AICA performing flight DE-1412 from Munich (Germany) to Fuerteventura,CI (Spain), was enroute at FL340 near…
Subscribe today
Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.
Pick your plan and subscribePartner
A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.
ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.
Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.
AeroInside Blog
Popular aircraft
Airbus A320Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American AirlinesUnited
Delta
Air Canada
Lufthansa
British Airways