Lion Air Flight 904

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 13 April 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 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.[1][2]

Lion Air Flight 904
The Boeing 737 as it came to rest after impacting the shallow waters
Accident
Date13 April 2013 (2013-04-13)
SummaryCrashed into the sea on approach; controlled flight into terrain
SiteOff Ngurah Rai International Airport, Denpasar, Bali, Indonesia
8°44′57″S 115°8′29″E
Aircraft
Aircraft typeBoeing 737-8GP
OperatorLion Air
IATA flight No.JT904
ICAO flight No.LNI904
Call signLION INTER 904
RegistrationPK-LKS
Flight originHusein Sastranegara International Airport, Bandung, Indonesia
DestinationNgurah Rai International Airport, Denpasar, Indonesia
Occupants108
Passengers101
Crew7
Fatalities0
Injuries46
Survivors108

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.

Aircraft
A Lion Air Boeing 737-800 similar to the one involved in the accident

The Boeing 737-8GP, registration PK-LKS, was owned by leasing company Avolon. It was received new from Boeing by Lion Air's subsidiary Malindo Air less than two months before the accident, on 21 February 2013. It was then transferred to parent Lion Air in March. The aircraft had been in service for less than six weeks with Lion Air before the accident.[3] At the time of the accident, Lion Air had 16 other Boeing 737-800 in the fleet.

Crew and passengers

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 Indonesian, one French, one Belgian, and two Singaporean. 6 of the crew were Indonesian while one came from India.[4]

The captain was 48-year-old Mahlup Ghazali, an Indonesian national who joined Lion Air in 2013 and had logged 15,000 hours of flight experience, including 6,173 hours on the Boeing 737.[5][6] The first officer was 24-year-old Chirag Kalra, an Indian national who had 1,200 flight hours, with 973 of them on the Boeing 737.[5][7]

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.[8] There has been no indication that the aircraft suffered any mechanical malfunction.[9] A final report was published in 2014.[5]

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.[10]

The NTSC concluded that the flight path became unstable below minimum descent altitude with the rate of descent exceeding 1000 feet per minute. Analysis of the pitch angle versus engine power based on the flight data recorder "indicated that the basic principle of jet aircraft flying was not adhered during manual flying."[5] 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.[5]

See also

References
  1. Hradecky, Simon (1 May 2013). "Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea". The Aviation Herald. Retrieved 9 May 2013.
  2. Arif Haryanto. "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)" (in Indonesian). Angkasa Pura Airports. Archived from the original on 1 February 2014. Retrieved 16 April 2013.CS1 maint: bot: original URL status unknown (link)
  3. "PK-LKS Lion Airlines Boeing 737-8GP(WL) – cn 38728 / ln 4350". Planespotters.net. 13 April 2013. Retrieved 13 April 2013.
  4. Henrykus F. Nuwa Wedo (15 April 2013). "MUSIBAH LION AIR: 4 Warga Negara Asing Jadi Korban". Bisnis.com. Archived from the original on 8 November 2018. Retrieved 8 November 2018.
  5. "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" (PDF). National Transportation Safety Committee. Archived from the original (PDF) on 29 November 2014. Retrieved 21 November 2014.
  6. "Lion Air Bantah Ghozali Lewati Batas Jam Kerja" [Lion Air Denies Ghozali Has Exceeded Working Hours]. Metro TV (in Indonesian). 13 April 2013. Archived from the original on 22 April 2013. Retrieved 26 August 2020.
  7. Firdaus, Fahmi (15 April 2013). "Kecepatan Lion Air Capai 350 Km Jam" [Lion Air Speed Reaches 350 Km Hours]. nasional.okezone.com (in Indonesian). Archived from the original on 22 April 2013. Retrieved 26 August 2020.
  8. http://www.cockpitchatter.com/final-report-lion-air-flight-904-pilot-error/
  9. "Preliminary Report No. KNKT.13.04.09.04" (PDF). National Transport Safety Committee. 14 May 2013. Archived from the original (PDF) on 10 August 2013. Retrieved 21 November 2014.
  10. "Bali crash pilot 'hallucinated', says Indonesia anti-narcotics boss". Sydney Morning Herald. 14 January 2017. Retrieved 15 January 2017.
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