Thursday, September 04, 2014

Pilot Errors Blamed for 2013 Indonesian Jet Crash: Accident Underscores Issues Safety Experts Say Continue at Fast-Growing Asian Aviation Markets

The Wall Street Journal 
 By Andy Pasztor
Sept. 4, 2014 4:52 p.m. ET

Repeated pilot mistakes and violations of basic safety procedures led to the crash of an Indonesian jetliner on a domestic flight in April 2013, according to investigators.

Pilots of the Lion Air Boeing 737 descending to land at Bali failed to adequately communicate with each other or properly monitor their position during an approach in stormy weather, according to the final report released recently by Indonesian authorities. The crew descended much rapidly and ended up too low without seeing the airport, and then waited too long to try to climb away from the strip, the investigation concluded.

No one was killed in the crash, but four passengers were seriously injured as the aircraft, which was only two months old and had no malfunctions of any kind, broke apart after slamming into the ocean less than a quarter of a mile short of the strip.

The accident has underscored shortcomings in training and cockpit discipline, issues that safety experts say continue to surface at various carriers serving fast-growing aviation markets in parts of Asia and elsewhere.

A spokesman for the airline didn't have any immediate comment.

The report said the crew exhibited "inadequate situational awareness" and failed to properly control the plane's speed using engine adjustments and its descent by changing the angle of the nose.

Investigators concluded that the flight crew failed to adhere to "the basic principles of jet flying."

The report, among other things, notes that at an altitude of roughly 200 feet the co-pilot indicated it was "totally dark" as the plane entered an intense patch of rain and his view of the airport was completely obscured by the storm cell. But the report indicates the captain didn't try to break off the approach until the plane was about 20 feet above the ground—a point at which it is virtually impossible to rev up the engines and climb away safely. The crash occurred a second later.

Typical airline safety procedures—buttressed by landing guidelines developed by international safety groups—require a go-round hundreds of feet higher if the strip isn't in sight.

In this case, according to investigators, the cockpit-voice recorder indicates the co-pilot said he didn't see the runway starting from a height of 900 feet. The report indicates the captain opted to press on with the descent, expecting to see the strip any second.

Years before the crash, according to the report, a trainer emphasized the captain's habit of continuing to descend and land during simulator sessions even if he violated mandatory criteria for "stabilized approach."

During the accident flight, the relatively inexperienced co-pilot handed over the controls to the captain shortly before the crash. And the plane's nose was pointed slightly downward just before impact, rather than pointing slightly up as required by flight manuals.

In addition, investigators said the co-pilot mistakenly attempted to evacuate passengers using one of the cockpit windows.

The preliminary report issued in May 2013 urged the carrier to ensure its pilots are properly trained in "changeover of control at critical altitudes and critical time."

Lion Air has become Indonesia's largest airline and one of the fastest-growing carriers in the world by rapidly rolling out new low-cost service across the Indonesian archipelago.

In the wake of the crash, the carrier enhanced its training focusing particularly on manual flying skills and decision-making during landing approaches.

According to the final report, the weather was clear four minutes before the accident but changed quickly.

The report includes recommendations dealing with more-effective ways to pass on the latest weather information, along with stepped-up pilot training. It also urges enhanced training for cabin crews in evacuating an aircraft.

- Source:

 NTSB Identification: DCA13RA074
Accident occurred Saturday, April 13, 2013 in Denpasar, Indonesia
Aircraft: BOEING 737, registration:
Injuries: 20 Minor,88 Uninjured.

This is preliminary information, subject to change, and may contain errors. The foreign authority was the source of this information.

On April 13, 2013, at about 1515 local time, Lionair flight JT-904, a Boeing 737-800, registration PK-LKS, crashed while on approach to Denpasar-Ngurah Rai Bali International Airport (DPS), Denpasar, Indonesia. Reports indicate that there were no fatalities; however, there were multiple injuries to the 101 passengers and 7 crew onboard. The domestic flight originated in Bandung Airport (BDO), Bandung, Indonesia. Weather reported at the time of the accident was wind 090 degrees at 6 knots, visibility greater than 10 kilometers, and ceiling broken at 1,700 feet above ground level.

The accident is being investigated by the National Transportation Safety Committee (NTSC) of Indonesia. In accordance with ICAO Annex 13, the NTSB has appointed a U.S. Accredited Representative as the State of Manufacture and Design of the airplane.

All inquiries should be directed to the NTSC at the following:

National Transportation Safety Committee
Ministry of Transportation Building 3rd Floor
Jl. Medan Merdeka Timur No. 5

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