Lion Air Undershot Runway at Denpasar and Crashed into the Sea

[Cire 0]

here' s the findings...

 

JAKARTA : Indonesian authorities blamed poor training for a crash in which a rookie pilot undershot the runway and landed in the sea off the resort island of Bali last month, according to a report seen Wednesday.

All 108 passengers and crew survived the spectacular April 13 crash, which split the new Boeing 737-800 in two and was a major blow to Lion Air, which has signed record plane orders but is trying to shake off its poor safety record.

The preliminary investigation by the National Transport Safety Committee found the 24-year-old Indian national at the plane’s helm was forced to hand control to the Indonesian captain since he could not see the runway upon descent.

The switch was made at 150 feet (46 metres) — below the minimum altitude considered safe to continue descending — and the captain ordered the plane to go around just one second before it crashed into the sea.

The report recommended Lion Air immediately implement several safety measures, such as reviewing “the policy and procedures regarding the risk associated with changeover of control at critical altitudes or critical time”.

The airline should also reiterate safety protocols related to minimum altitudes to its pilots, it said.

The report described a sudden change in weather, with clear visibility minutes before the flight landed changing to rain and very poor visibility seconds before.

While a full investigation will determine the exact cause, the preliminary report ruled out any fault with the aircraft.

Lion Air was little-known internationally until it struck two of the world’s largest aircraft orders worth a staggering $46 billion.

In March Lion Air ordered 234 medium-haul A320 jets worth $18.4 billion euros ($24.2 billion) from Europe’s Airbus to boost its expansion as air travel booms in the fast-developing nation of 240 million.

That order followed its $22.4 billion order for 230 Boeing 737 airliners in 2011.

But experts have raised concerns there is a lack of qualified pilots in Indonesia to fly the fast-increasing number of planes acquired by Lion Air.

Along with with most Indonesian airlines, it is banned from US and European skies for safety reasons.

Between 2004 and 2006 Lion Air suffered a series of six accidents which all involved planes overshooting or missing the runway. No one died.-- AFP

Read more: Indonesia says poor training caused Bali sea crash - Latest - New Straits Times http://www.nst.com.my/latest/indonesia-says-poor-training-caused-bali-sea-crash-1.279725#ixzz2TPQBJHc5

[Gavin Andrew David 6]

Very disturbing outcome, I have so may things running through my head right now about what could've been done, or what should've been done. It is disturbing.

 

We should see the vertical approach profile... I bet they probably winged this VOR approach. but this just my 2 cents

[wee c k 0]

best guess VOR approach.. the approach actually is not a straight in approach, plus denpasar legendary crosswind.. d copilot most probably wasnt aware that the runaway is further left/right of the normal view of the runaway from the cockpit. but then its not a valid reason to hand over the control to d boss.. kalau nk hand over ctrl pun biar la b4 minimum.. its just good airmanship.. mean while, the boss terkejut kena hand over control last minute actually see the runaway, try to turn d aircraft towards d runway tp bcoz of too much input on d control column the aircraft jd more unstable than before.. d moment he decide to go around, its a bit too late... they r just lucky enough to get away with no casualty..

 

anyway d decision to go around or not sometimes r hard to explain.. there r ppl with itchy fingers... means, no issues pressing TOGA.. there r ppl with 'pride'.. try their best to control n land d aircraft.. d latter kind of person is dangerous.. n sometimes need reminder from d other guy beside him/her.. 'CAPT U MUST LISTEN!'.. 'CAPT GO AROUND' then he/she will realize its a bit too much from him/her n go around..

 

well capt radzi can explain more bout this...

wind from tower observation can be different in flight.. they r measured on ground normally at the touchdown zone.. without d effect of terrain mostly, the 'upper' wind can jump up to +10/+15 kts.. but in some cases can b a lot higher even with just couple of hundreds ft above the gound.. plus sometimes they can 'swing' from left to right.. that is even worse.. u'll be fighting for control then...

[Arthur Van Straten 0]

@ Gavin A.D.

The approach path of the aircraft is on Fig 2, in the report.

As it was a non aligned NPA, one should be visible at minimums, as with all approaches at minimums. If not visible, you go missed.

Now, the report gives no evidence that they were not rwy in sight at minimums, so maybe they where, continued, and lost contact again a little bit later. If this happens, you must go missed, no two ways about it. There maybe was still time to do it correctly and it should have been done, was it not alone for sheer basic survival instinct. People normally have such instinct, since the Neanderthalers.

(That the SIC did not do such could have multiple reasons. There are a few which are obvious but this is not the place and time to discuss them. Hopefully the final report will address it and the airline and similar airlines will learn from it.)

Further, in general.

As the SIC was still PF at that time, he should have initiated a missed approach but, he did not and at 150 ft. he gave control to the PIC with saying, “ I dont see the runway”.

Now, at 150 ft, with no contact, you do not have much time anymore and by dumping the aircraft in the other guys lap, basically saying, “I don’t know anymore, you sort this mess out” , the other guy has a brain scramble to figure out what is what and that also take precious time. When the PIC finally got his priorities sorted out, it was too late.

This crew had more than one chance to correct a wrong and make it right. They did no such thing. As to why and how, also here we better wait and see if the next report will address these issues. So far, the present report is indeed, preliminary.

As for the posting of “wee c k”, I leave it to Capt. Radzi to educate you further on the ins and outs of handing over control at the flight deck.

One last observation, and I may stick my neck out here, is that if I was at DCA Putrajaya, I would observe Malindo like a hawk, as Malindo is Lion Air. But this is a personal opinion.

 

Cheers

Art.

Edited May 18, 2013 by Arthur Van Straten

[flee 5]

Agree that DCA should watch Malindo carefully. As the airline is planning to expand aggressively, junior pilots will start to occupy their cockpits soon. This is when mistakes can prove to be costly and, maybe, fatal.

[Lock SH 0]

As I mentioned in my previous post in this thread, it is bogged down to the quality of training and safety culture in the company. How much the company is willing to spend on training and how transparent is the company to an external, highly recognised audit agency. As long as they never open their doors to a comprehensive and continous external audit, they can dream on to be a safe operators.

 

I, personally refrained myself and family to be onboard of any Indon carriers until such time their safety record is beyond reasonable doubt, not even on Air Asia Indonesia or Garuda.

 

MALINDO is a different matter. It is registered in Malaysia, operating under Malaysian AOC/AOP and regulated by Malaysian DCA. DCA Malaysia is also subjected to rigorous audit by FAA & JAA as well and currently holding the highest category of ratings by these 2 agencies.

 

As far as I am aware, our DCA is yet to have 'Bisa Di Atur Pak' attitude and lets keep it that way. DCA had rejected all foreign nationality (read: Indons) to be the company's appointment holders, not even a training captain. This is to ensure the quality of MALINDO pilot is consistent with MAS / Air Asia or meeting the DCA standards.

 

If DCA could only renewed 6 months AOC to Air Asia Malaysia before because of not meeting the standard required during audit, the same agency has no problem to do the same to any local operator.

 

FYI, most of the appointment holders in MALINDO are ex-MAS / Firefly / Air Asia /MasWings anyway and each of them was interviewed personally by DCA before they could assume their roles.

 

 

[Amirul Mazlan 0]

Flee, if you worry about junior pilots occupying right seat, you might as well need to worry when you fly air asia, mas or firefly since training are continuous, with more fresh cpl holders coming on stream on these multi crew aircraft, regardless of airline.

[flee 5]

Flee, if you worry about junior pilots occupying right seat, you might as well need to worry when you fly air asia, mas or firefly since training are continuous, with more fresh cpl holders coming on stream on these multi crew aircraft, regardless of airline.

It is the company culture. Lion Air company culture is not one of "safety first". As can be seen, the flight crew of the Bali crash did not observe SOPs at all - a result of the poor training they received.

 

Currently, Malindo aircraft is being flown by people who are not trained by Lion Air. If Malindo's junior pilots are trained by Lion Air, then one will have great doubts about the training that they will receive.

 

If one is flying on a Lion Group airline, it would not be unreasonable to assume that the safety standards may not be as high as on other airlines.

[Arthur Van Straten 0]

Let me chip in here for a moment if I may.

As for the quality of the post holders of Malindo, one can indeed expect that the DCA has properly vetted those candidates and that their qualifications are up to the mark.

Nobody has said here in this topic that the DCA maybe is Bisa Di Atur Pak, (yes, I know what that

means), but what was said here, I did that, that if I was with the DCA I would watch Malindo as a hawk.

One can have the best post holders in the market but as the company culture of the parent company does not adhere to their own operational manuals and procedures, as recent history has shown us, and undue pressure on operational staff is applied, than the end result can be disastrous. It is indeed up to the post holders to be that safety valve in the Malindo organization
and indeed the DCA should look over their shoulders.

Do I criticize these post holders here? Nope, they have a tough job to do and need all the help they can get.

Malindo got their AOC in record time, most probably based on Lion Air’s manuals and maintenance programs, and it is up to these post holders that what is written in the manuals will be applied rigorously and when need be, they should stamp their foot down if needeed to insist to do things right.
At the end of the day it boils down to the basic principle that the owners of the business let the professionals do their work.

If that principle cost more money than the owners want to spend and that budgets which were put on paper at the beginning will not be allocated, then yes, we need a DCA which is one front with the post holders.

I hope I have clarified my previous statement in an earlier post.

As far as flee’s concern regarding young rookie pilots, I like to add as follows.

There is nothing wrong with employing 200 hours CPL holders to the right hand seat, provided, they are properly trained and are being integrated into a professional safety culture. There is nothing new here. KLM/Air France, Lufthansa, BA, SQ, have been doing that since their inception and when they hire and train these kids they do not hire and train career F/O’s. They hire and train future Captains.

Flee is not disagreeing with that, he is merely saying that when you just hire warm bodies to occupy the right hand seat and let them pay for that privilege some more, without industry conform salaries and in-house continues training than yes, one should be worried.

So, yes, I would watch Malindo like a hawk.

Cheers
Art

 

 

 

 

[Radzi 2]

 

There is nothing wrong with employing 200 hours CPL holders to the right hand seat, provided, they are properly trained and are being integrated into a professional safety culture. There is nothing new here. KLM/Air France, Lufthansa, BA, SQ, have been doing that since their inception and when they hire and train these kids they do not hire and train career F/O’s. They hire and train future Captains.

 

Same here, at least with MH.

 

Beware of any airline that doesn't let their co-pilots to handle their aircraft because that shows some deficiencies in their training.

Edited May 20, 2013 by Radzi

[JuliusWong 0]

I was looking through my images file, and found this:

 

 

PK-LKS B737-8GP, a day before it was transferred back to Lion Air. I think I have more images of her hidden somewhere. Never know such a young aircraft will die a premature death.

Edited July 7, 2013 by JuliusWong