Incident Overview

Date: Saturday 13 April 2013
Aircraft Type: Boeing 737-8GP (WL)
Owner/operator: Lion Air
Registration Number: PK-LKS
Location: Denpasar-Ngurah Rai Bali International Airport (DPS) – ÿ Indonesia
Phase of Flight: Approach
Status: Substantial, written off
Casualties: Fatalities: 0 / Occupants: 108
Component Affected: Aircraft Flight Control System (primarily the autopilot and control surfaces).Aircraft Flight Control System (primarily the autopilot and control surfaces).
Investigating Agency: NTSCNTSC
Category: Accident
A Lion Air Boeing 737-800 experienced a sudden and catastrophic loss of control during final approach to Denpasar-Ngurah Rai Airport, resulting in a water landing. The flight crew, including the pilot and copilot, successfully executed a go-around, but the aircraft impacted the water with significant damage. Initial observations indicate a rapid descent, an inability to ascertain the runway, and a failure to effectively execute a go-around due to insufficient altitude. The incident highlights a combination of factors including unstable flight path, situational awareness lapses, inadequate weather information, and a critical decision-making error regarding the go-around procedure.A Lion Air Boeing 737-800 experienced a sudden and catastrophic loss of control during final approach to Denpasar-Ngurah Rai Airport, resulting in a water landing. The flight crew, including the pilot and copilot, successfully executed a go-around, but the aircraft impacted the water with significant damage. Initial observations indicate a rapid descent, an inability to ascertain the runway, and a failure to effectively execute a go-around due to insufficient altitude. The incident highlights a combination of factors including unstable flight path, situational awareness lapses, inadequate weather information, and a critical decision-making error regarding the go-around procedure.

Description

Lion Air flight 904, a Boeing 737-800, came down in the sea while on final approach to Denpasar-Ngurah Rai Bali Airport, Indonesia; all 108 occupants survived the accident. Flight JT-904 departed originated at Palu Airport (PLW), Indonesia and was bound for Denpasar (DPS), Indonesia with en route stops at Balikpapan Airport (BPN), Banjarmasin Airport (BDJ) and Bandung Airport (BDO). The flight departed Bandung at 13:45 with the copilot as Pilot Flying. About 15:00 the flight was descending towards Bali and the crew received vectors for a VOR DME approach for runway 09. At 15:08, with the aircraft at approximately 1,600 ft AGL, the Tower controller saw the aircraft on finals and gave a landing clearance with additional information that the wind condition was 120ø at 5 kts. While descending through 900 feet the copilot stated that the runway was not in sight. Since the captain noted a flashing light at the beginning of the runway, he responded: “OK. Approach light in sight, continue”. At 15:09:33, after the EGPWS called out “Minimum” at an altitude of approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle and continued the descent. The airplane then entered an area of rainfall and the outside environment became totally dark. At 150 ft AGL the captain took over control. The copilot handed the control to the captain and stated that he could not see the runway. At 15:10:01, the EGPWS called out “Twenty”, and the captain commanded a go around. One second later the aircraft impacted the water. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south west of the beginning runway 09. Contributing Factors: – The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots. – 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 descends altitude (MDA). – The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully. – The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.

Source of Information

http://www.skybrary.aero/index.php/B738,_vicinity_Denpasar_Bali_Indonesia,_2013_(CFIT_HF)http://www.skybrary.aero/index.php/B738,_vicinity_Denpasar_Bali_Indonesia,_2013_(CFIT_HF)

Primary Cause

Combination of unstable flight path, insufficient altitude for a go-around, and inadequate weather information leading to a loss of situational awareness and a critical decision to initiate a go-around.Combination of unstable flight path, insufficient altitude for a go-around, and inadequate weather information leading to a loss of situational awareness and a critical decision to initiate a go-around.

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