Lion Air Flight 904

Lion Air Flight 904
	The Boeing 737 as it came to rest after impacting the shallow waters
Accident
Date	13 April 2013
Summary	Crashed into the sea on approach; controlled flight into water; failed go-around attempt
Site	Off Ngurah Rai International Airport, Denpasar, Bali, Indonesia ; 8°44′57″S 115°8′29″E / 8.74917°S 115.14139°E
Aircraft
Aircraft type	Boeing 737-8GP
Operator	Lion Air
IATA flight No.	JT904
ICAO flight No.	LNI904
Call sign	LION INTER 904
Registration	PK-LKS
Flight origin	Husein Sastranegara International Airport, Bandung, Indonesia
Destination	Ngurah Rai International Airport, Denpasar, Indonesia
Occupants	108
Passengers	101
Crew	7
Fatalities	0
Injuries	46
Survivors	108

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 April 13, 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 3:10 pm, the aircraft crashed approximately 1.1 kilometres (0.6 nmi) 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]

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.

Background

Aircraft

The aircraft involved was a 53-day-old Boeing 737-8GP with serial number 38728 and registered as PK-LKS. It had logged about 142 hours and 37 minutes of flight time in 104 takeoff and landing cycles. It was manufactured by Boeing Commercial Airplanes on 19 February 2013 and was powered by two CFM International CFM56-7B24E engines.^[3]^: 19

Crew and passengers

The captain was 48-year-old Mahlup Gozali, an Indonesian national who joined Lion Air on 3 February 2003 and had logged 15,000 hours of flight experience, including 6,173 hours and 53 minutes on the Boeing 737.^[4]^[3]^: 14–15 His co-pilot was 24-year-old Chirag Kalra, an Indian national who had 1,200 flight hours, 923 of which were on the Boeing 737. He joined Lion Air on 25 April 2011.^[5]^[3]^: 15–16

There were 2 pilots and 5 flight attendants with 101 passengers on board consisting of 95 adults, 5 children and 1 infant. 97 passengers were Indonesians, 1 French, 1 Belgian, and 1 Singaporeans. 6 of the crew were Indonesian while one came from India.^[6]

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) above ground level (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 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 metres (49 ft), as 9 metres (30 ft) of altitude is lost when executing the manoeuvre.^[7] There has been no indication that the aircraft suffered any mechanical malfunction.^[8] A final report was published in 2014.^[3]

In January 2017, Budi Waseso, the chief of Indonesia's national narcotics agency, alleged 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 directly contradicted the statement made after the accident by Indonesia's transport ministry, which said the pilots had not tested positive for drugs.^[9]

The NTSC concluded that the flight path became unstable below minimum descent altitude with the rate of descent exceeding 300 metres per minute (1,000 ft/min). Analysis of the pitch angle versus engine power based on the flight data recorder,^[3]

indicated that the basic principle of jet aircraft flying was not adhered during manual flying.

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.^[3]

References

^ 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.
^ Haryanto, Arif. "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.{{cite web}}: CS1 maint: bot: original URL status unknown (link)
^ ^a ^b ^c ^d ^e ^f "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.
^ "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 5 March 2016. Retrieved 26 August 2020.
^ 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 19 April 2013. Retrieved 26 August 2020.
^ 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.
^ "Final Report Lion Air Flight 904 – Pilot Error - Cockpit Chatter". Archived from the original on 1 June 2015. Retrieved 2 May 2015.
^ "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.
^ "Bali crash pilot 'hallucinated', says Indonesia anti-narcotics boss". Sydney Morning Herald. 14 January 2017. Retrieved 15 January 2017.