Lion Air Flight 904
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Lion Air Flight 904 was a scheduled domestic passenger flight, flying from Husein Sastranegara International Airport in Bandung to Ngurah Rai International Airport, Bali, Indonesia. On 13 April 2013, the Boeing 737 operating the route while on final approach crashed into water short of runway. All 101 passengers and 7 crew on board survived the accident. The aircraft involved was a Boeing 737-800, registration PK-LKS, operated by Lion Air between Husein Sastranegara International Airport in Bandung, Indonesia and Denpasar. At 15:10 local time (07:10 UTC), the aircraft crashed approximately 0.6 nautical miles (1.1 km) 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.
The airport was closed for around ninety minutes while emergency services attended the scene.At the time of the accident, Lion Air had 16 other Boeing 737-800 in the fleet.
Investigators published the final report and concluded that pilot error was the cause of the crash. The investigation determined that there were no issues with the aircraft and all systems were operating normally. The investigation concluded several factors to this accident were the pitch angle versus engine power on the FDR data indicated that the basic principle of jet aircraft flying was not adhered during manual flying, aircraft flight path became unstable below MDA when the rate of descend exceeding 300 metres per minute, in which this situation was not recognised by both pilots, and the Captain's decision to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully. 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 descend altitude (MDA), thus, the plane crashed into the water
Investigators published the final report and concluded that pilot error was the cause of the crash. The investigation determined that there were no issues with the aircraft and all systems were operating normally. The investigation concluded several factors to this accident were the pitch angle versus engine power on the FDR data indicated that the basic principle of jet aircraft flying was not adhered during manual flying, aircraft flight path became unstable below MDA when the rate of descend exceeding 300 metres per minute, in which this situation was not recognised by both pilots, and the Captain's decision to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully. 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 descend altitude (MDA), thus, the plane crashed into the water
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 142 metres (466 ft) AGL. The report found that at 270 metres (890 ft) AGL, the first officer reported that the runway was not in sight. At approximately 46 metres (151 ft) 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 6.1 metres (20 ft) 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 15 m, as 9 m of altitude is lost when executing the manoeuvre. There has been no indication that the aircraft suffered any mechanical malfunction. A final report was published during 2014.
In January 2017, Budi Waseso, the chief of Indonesia's national narcotics agency, said 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 is at odds with the statement made after the accident by Indonesia's transport ministry, which said the pilots had not tested positive for drugs.
The NTSC concluded that the flight path became unstable below minimum descent altitude with the rate of descent exceeding 1000 feet per minute. 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.
In January 2017, Budi Waseso, the chief of Indonesia's national narcotics agency, said 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 is at odds with the statement made after the accident by Indonesia's transport ministry, which said the pilots had not tested positive for drugs.
The NTSC concluded that the flight path became unstable below minimum descent altitude with the rate of descent exceeding 1000 feet per minute. 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.
Incident summary | |
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Date | 13 April 2013 |
Summary | Landed short of runway in the water |
Site | Ngurah Rai International Airport, Denpasar, Bali, Indonesia |
Passengers | 101 |
Crew | 7 |
Fatalities | 0 |
Injuries (non-fatal) | 46 (including 4 serious) |
Survivors | 108 (all) |
Aircraft type | Boeing 737-800 |
Operator | Lion Air |
Registration | PK-LKS |
Flight origin | Husein Sastranegara International Airport, Bandung, Indonesia |
Destination | Ngurah Rai International Airport, Denpasar, Indonesia |
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