Lionair plane down in Bali.

[Jet Jockey]

I have operated for some 15 years onto that Rwy in Bali. It's a straight forward vor approach over water. It is offset to the Rwy and does require re aligning at 500 feet for final. At that time of the day the papi lighting is virtually useless due to salt spray with the red lights generally indistinguishable. It can appear 4 white lights with salt spray and the bright sun behind the aircraft shining directly on the lights. The last bit of the approach is over shallow reef which is covered at high tide and exposed in patches at low tide. You can have rolling waves rolling across the reef in the landing direction toward the end of the sea wall and Rwy which can be a little disconcerting. I would say very lucky the plane not more badly damaged with serious loss of life. It's quite a long Rwy for 737 ops.

[ExSp33db1rd]

.........and the rule of five times your ground speed to give you a 3 degree glideslope descent rate...5x140=700 fpm.

I found half the groundspeed in hundreds easier to remember i.e. 7 - hundred - in your example. ( I know, I know, just use the first digit. )

[Transition Layer]

Someone mentions from one of the planefinder tracks that the Virgin aircraft is circling.

I know for a fact they went around due weather. They were number 2 behind the Lion Air aircraft. This comes direct from a mate in Virgin.

So despite the METAR evidence, there was obviously some sort of weather phenomena affecting the approach path around about the time Lion Air made their approach.

[PENKO]

ATC Watcher, it's still NOSIG... CB does not equal TS.
Lancer, just to be sure we understand each other, NOSIG means NO SIGNIFICANT CHANGE.

Nothing to do with the severity of the wx.

[golfyankeesierra]

Finally someone (Indolion), supposedly closer to the action, gives us some information and it is totally ignored:
Dear Colleagues,
As we heard a news that today one of our colleague got serious accident at Bali.
JT 904 / PK LKS / B 737-800 NG
Stretch : BDO-DPS
PIC : Capt. Mahlup Gozali (Local)
SIC : FO . Chirag Kalra (Indian)

Everyone onboard include active crew has been evacuate and no fatalities.
We highly appreciate with their good job and excellent professionalism.
Now we need all colleague to keep focus on your job and give service excellent to all passenger by giving a flight announcement with warm greetings. We need to keep all passenger feel safe to fly with Lion Air.
Last time kindly to remind you that always be aware of sudden windshear or any kind of weather phenomena that would result on speed drop and even worse aircraft sink especially on very short final position. Don't hesitate to put more additional thrust to disseminate this event and if abnormal thrust position reach it means the stabilized approach criteria has been breach and this is the alert for us to commence immediate GO AROUND. At this time REJECT LANDING Go Around procedure must be comply accordingly.
Finally my colleague I would like to say SAFETY IS COMES FROM OUR DICIPLINE. Always Keep alert and Have a safe flight.
God bless us.
Sincerely yours,

First of all, as it is not really level 6 English, let me ask is this a babel fish translation or are these actually the words of your chief pilot?

He specifically addresses windshear, wonder if it is a general caution or whether he is acting on known facts. We will probably know when/if Boeing publishes a reminder of windshear recovery also...

[India Four Two]

Slight thread drift, since it has already been clearly established that this was an undershoot accident, but there was a 09 overrun accident in Dec 1984. A Garuda DC-9 landed 20 kts too fast, 1800 m down the runway (2700 m in those days). Not surprisingly, it ran off the end and broke into three pieces and caught fire. Amazingly everyone survived.

I drove past the site the next day. It was in the mangrove swamp about half-way between the 27 threshold and the Nusa Dua road. A thriving restaurant village had sprung up overnight, to cater to the hordes of curious sight-seers.

[philipat]

Just my HO but based on my on the scene opinion, the conditions for windshear were simply not present, And, IAC, I thought that the 73NG was equipped with WS Doplar? 73 Drivers please advise.

[BPA]

Transition Layer,

Heard the same from a mate at Virgin Australia.

[golfyankeesierra]

I agree WS wouldn't be likely, but with CB's around, plus what "transition layer" remarks a few posts above, I wouldn't rule it out.
NG's have AFAIK both Predictive windshear PWS, which is doppler radar based, and Reactive windshear RWS which is flight data based.

[BARKINGMAD]

I hope when the investigators look at the FDR that they find Cont Ign selected ON as per landing checklist and/or Flight In Heavy Rain.

IF there was a CuNimb leaking and a typical rain shower for the tropics then maybe the flames went out? Just a thought. :suspect:

[lear999wa]

The NG has auto-relight protection, I doubt this was caused due to a flame out situation.

[philipat]

Sorry, but AGAIN, I live on the spot in Bali and was here yesterday afternoon at the time of the accident. I live 4 miles to the East of the field and there was some low cloud and a few local rain showers but NO TS activity at the time. The winds were very light from the SE so, of course, conditions to the West of the field on approach MAY have been different, but unlikely in my experience of Bali weather conditions for over 30 years living in Bali because, with weather from the SE, that would have passed through here first. And it didn't.

[BARKINGMAD]

According to Mr Boeings book "whenever the EECs detect a flame-out".......

At less than 500' on the approach it's a bit late for the AUTOMATICS to start attempting to relight don'tya think? :ugh:

[Luke SkyToddler]

In Indonesia, it takes a little time to find the right investigators who will produce the correct crash findings, for the right amount of money. One mustn't rush these things. I won't even mention the Will of Allah!
That right there is the root of the problem ... EVERYTHING is for sale in Indo if the price is right : the job, the licence, the skill test, the maintenance release, even the accident investigator findings. Look at the Silkair suicide fiasco or indeed the recent history of Lionair itself with regard to tail strikes and overruns ... and then look at the Indo CAA response ... corruption is like breathing down there, it's just a way of life. Expect absolutely nothing to change in the face of this latest embarrassment.

[framer]

On the NG you don't need to have the start switches in cont because the ignightors fire up automatically when the flap comes out.
So who is right, third hand Virgin Australia info or phil pat?

[smiling monkey]

Someone mentions from one of the planefinder tracks that the Virgin aircraft is circling.

I know for a fact they went around due weather. They were number 2 behind the Lion Air aircraft. This comes direct from a mate in Virgin.

So despite the METAR evidence, there was obviously some sort of weather phenomena affecting the approach path around about the time Lion Air made their approach.

And therein lies the difference between the two airlines (which includes their SOPs and safety culture); one continues the approach, the other goes around.

[ia1166]

Embarrassment? Big words when we don't know anything yet.

Just had look at this thread. From the comments against P2F ( he wasn't solo you know) to the bloke that says flying below the notional 3 degree glide slope on a NPA is a good idea so you can level off early??? ( where the chuffing hell does he come from?) to the blame Indo Authority game.

And the guy banging on about the RAF? Maybe he needs to revisit a certain Tristar incident at Brize a few years back.

Plenty of examples of poor pilots across the pond too.

Nobody here is infallible gents.

Please can you give the guy the benefit of the doubt until we know. It could have been any number of things.

90% of the input here is utter rubbish.

[BARKINGMAD]

Framer, ta for the tip re flap deployment activating the ignitors, can you please refer me to the relevant entry in OM B as I'm unable to locate any connection with flaps beyond EECs setting new idle settings?

[Transition Layer]

Sorry, but AGAIN, I live on the spot in Bali and was here yesterday afternoon at the time of the accident. I live 4 miles to the East of the field and there was some low cloud and a few local rain showers but NO TS activity at the time. The winds were very light from the SE so, of course, conditions to the West of the field on approach MAY have been different, but unlikely in my experience of Bali weather conditions for over 30 years living in Bali because, with weather from the SE, that would have passed through here first. And it didn't.

No doubt you're the best person to pass comment on the weather, I was merely passing on some KNOWN info about a go-round due weather (since backed up by another poster).

There is definitely some heavy showers in the background of one photo (looking West). If the weather does move in from the SE as you say, and given the time between the crash and the photo, there's a fair chance those showers were close to the threshold as Lion made their approach.

Am I speculating about the weather? - YES
Am I speculating on the actions of the crew? - NO

:cool:

[1a sound asleep]

Culture of safety compromise and corruption. How quickly people forget Adam Air Adam Air - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Adam_Air#Incidents_and_accidents)

[wooski]

Hi Transition Layer, thanks for the info.
it was only my interruption as a SLF, the flightrack coverage seems poor there until the last final postions near the airport, so i thought they were circling after the lion went for a swim.

[1a sound asleep]

http://i50.tinypic.com/20pf02.jpg

The Jakarta Post, Denpasar | Archipelago | Sun, April 14 2013, 4:44 PM

An official said on Sunday that both the chief pilot and co-pilot of the Lion Air Boeing 737-800 aircraft that crashed on Bali on Saturday afternoon tested negative for narcotic and alcohol use.

The Transportation Ministry’s director general of air transportation, Herry Bakti S.Gumay, said a medical examination had found no evidence that Capt. Mahlup Gozali or co-pilot, Chirag Carla, had any health problem that would have played a role in the accident. The tests found no presence of drugs or alcohol in their bodies.

http://www.kedaiberita.com/images/resized/gambar/bisnis/pilot_lion_320_230.jpg

Jakarta Post, Jakarta | Archipelago | Sat, April 13 2013, 6:03 PM

Lion Air general affairs director Edward Sirait has said that there were no weather problems when a Lion Air Boeing 737-800 aircraft crashed on landing at Ngurah Rai International Airport, Bali, on Saturday afternoon.

He said the weather was quite good when the accident happened.

[Cereal Expert]

The winds were very light from the SE so, of course, conditions to the West of the field on approach MAY have been different, but unlikely in my experience of Bali weather conditions for over 30 years living in Bali because, with weather from the SE, that would have passed through here first. And it didn't.

May have been different? You betcha.....My birds eye view from the sands of Kuta Beach told a very different story. The approach area was occupied by an intense cell of heavy rain that had moved through Jimbaran Bay and continued slowly west and out to sea. What was left of it can be seen in the background of the published photos. I do not wish to dispute your expertise, rather I feel your doubt in the existance of any sort of significant weather event further suggests this wasn't just any light sun shower. It was black and it was solid.

[McBruce]

It's a limitation to put the start switches to cont for takeoff/landing. This gives flameout protection when N2 drops below a specific percent. I.e. the ignitors will kick in.

Given we've had a post containing info from the CP and as another poster kindly pointed out, it contains good info that's been ignored. It seems this could've been weather related....

[philipat]

Lion Air general affairs director Edward Sirait has said that there were
no weather problems when a Lion Air Boeing 737-800 aircraft crashed on
landing at Ngurah Rai International Airport, Bali, on Saturday
afternoon.

He said the weather was quite good when the accident
happened.


Thanks. that tends to confirm my earlier reports of the local weather at the time of the accident. Lion would surely reserve weather as a possible excuse unless the met data would confirm otherwise? I have no axe to grind here, I am simply reporting the weather conditions locally at the time of the accident. Of course, Virgin Australia may soon publicly report the reasons for the GA of their flight. Presumably, either weather OR the sight of a rather large and highly visible 73 on the reef at the 09 threashold??

[misd-agin]

If you had the FDR, what is the first thing you would want to know????

Everything. Single items will not tell the whole story.

[CONF iture]

@ IndoLion
Is it kind of official communication (http://www.pprune.org/7792698-post237.html) by the Airline ?
By Cheif Chimp do you mean Chief Pilot ?

@Capn Bloggs
Thanks for the VOR DME 09 approach plate.
Don't you know if there is a RNAV 09 as well ?

[IFixPlanes]

Automatic ignition is a option (ENGINE START Switche in AUTO):
provides automatic ignition to selected igniters when
• engine is running and,
• flaps are not up below 18000 feet altitude or,
• engine anti-ice is selected to ON.

[llondel]

I know for a fact they went around due weather. They were number 2 behind the Lion Air aircraft. This comes direct from a mate in Virgin.

Surely if the aircraft in front of you crashes, you ought to be going around anyway? Although in this case it didn't, aiming to fly low over a crashed aircraft might give more problems if it burst into flames. You'd be without safety cover too, if they've all headed off to deal with the first one.

[BOAC]

Let's try to summarise?:-

They ran out of fuel/engines flamed out because they didn't use ignition
They did not appear to use reversers or spoilers during the ditching and had the gear down
The weather was fine/thunderstorms/CBs/windshear/rain
They undershot 09/overshot 09 or 27
They didn't fly the ILS properly/messed up the VOR approach/had the wrong altimeter setting
The pilots were idiots/heroes/P2F and useless

All good stuff! Have I missed anything? We should be able to get something out of that lot.

[PJ2]

Yep. Why spoil good stories with flight data and audio recordings?

(...spoilers and reversers in the ditching....??, ...someone really said that?)

[BOAC]

#7 and possibly #205. Several 'opinions'/'questions' about gear.

[Clear_Prop]

I don't post very often on Pprune because its too much of a free-for-all sometimes, but I feel I have to add to the voices saying "Hold on, lets quit making judgements until all the facts are in the open!"

1. I think it is grossly unfair to heap blame on the crew when the evidence at this stage at least suggests whatever action they took saved everybody's lives. My personal view until we hear anything to the contrary is that if the crew were as incompetent as some people suggest they would be more likely to make a complete Horlicks of it, and most of the witnesses to the event would now be in body-bags. Talking of witnesses, here we have a WSJ article, written by a non-aviation journalist talking to a non-aviation witness, but it at least seems to independently corroborate the idea that the crew repositioned the flight path of the aircraft for a ditch, perhaps realising they were not going to make the runway:

Witness Tells of Watching Lion Air Jet Crash - Wall Street Journal - WSJ.com (http://stream.wsj.com/story/latest-headlines/SS-2-63399/SS-2-210895/)

2. Heaping blame on the country, and all the horrible racist comments some people have come out with. I think its fair to say Indonesia is an emerging country compared with Europe/US/CIS and maybe they have got some way to go yet... but I deal with the Indonesian authorities on a fairly regular basis and I don't think is fair to tar the whole industry there with the brush of corruption. It is fair to say there is a desire to get it right. For example, it is not easy to get a permit to take a large jet aircraft into the country and this is usually achieved with accurate legal documentation, not back-handers.

3. I've read some pretty unpleasant things about the airline, so I don't feel very obliged to jump to their defence, but whatever their internal cultural misgivings, this aircraft was BRAND NEW, there was hardly even time for their engineers to make a mess of it, on a statistical balance of probabilities, these guys have forty something of these planes to work on and ought to be pretty competent, but in the case of this aircraft they are unlikely to have even had a chance to look at it and say "ooh, nice paint".

4. Without wanting to add further speculation into the mix, but purely to add balance and emphasise that we really don't know enough yet... looking at the bigger picture it is worth considering that this BRAND NEW aircraft was recently assembled and delivered by a company who despite their excellent reputation in the field are currently dealing with having the entire fleet of their latest product grounded due to manufacturing and design defects.

I do hope the last point is not a factor as it could have far reaching consequences, but I just wanted to clarify that all we know is there was an incident, but other than that we have no clue whatsoever what the causes were. Nobody on this forum is going to pull the answers out of a bag, but it doesn't look like it is going to be a complicated problem for whoever investigates it to solve and report, so lets sit back and let them do their work. If there's any corruption involved in their findings I'm sure we'll smell it!



....as for the Virgin plane going around? If I was number 2 to a plane suddenly failing to make the runway in front of me I'd instinctively go around, wouldn't you?

[smiling monkey]

All good stuff! Have I missed anything? We should be able to get something out of that lot.

And how is this any different from all of the other accident/incidents discussed on pprune in the past? Leave the the investigation to the professional investigators; wait for the official report to be released, and only after that, can we expect to learn from what has happened. In the mean time, we continue to speculate what happened.

[lomapaseo]

it seems most likely that they were short on power on final

of course they would be since they descended into the water.

What counts is why

too slow a spool up vs descent rate? ala Capt Asseline ?

dual engine powerloss on landing ala BA B777 ?

commanded power not sufficient to achieve the runway?

I haven't seen a hint of facts to support any of the above scenarios as yet.

Anybody seen a peek at the condition of the fans on both engins Asymetric power ? undamaged blades?

[jeff748]

https://docs.google.com/viewer?a=v&q=cache%3A9TADceYaFxsJ%3Awww.cyberair-yssy.com%2FWADDALL.pdf+&hl=en&gl=ca&pid=bl&srcid=ADGEEShwD7v3QVjOMMBhb5meeBb-S4SIYoCTwHEXjng7NfhO3sn1YCBbK75RybNvlMEGT0wtI8x3V1u7MCDPMkp1 vNRUZg78MJZ9a2NOOxlw5YZ-j1uRMeGBKsId_81hGAAJDHgoUAqe&sig=AHIEtbT1zUHqO7qwjIYNG8GC-6kje_EPUg

[Toruk Macto]

Its all speculation .
Not sure about 737 but if missed approach is not at threshold then can a fully managed approach be done ? Should it be in a selected vertical mode ? If the A/C was low on app , had visibility problems due to unexpected rain shower it may have gone wrong very quickly . Engines not powered up due up drafts / shear maybe speed brake left out ? Got visual , to low , pull back , no power up or to much drag and splash .
How ever it happened its great no one died so have to be thankful for that .
Hope the authorities work out the underlying factors and use it to improve their industry .

[jetjockey696]

The dramatic crash of a Lion Air plane into the sea off Bali has raised fears Indonesia’s fastest-growing carrier may be putting passenger safety at risk with its huge expansion plans, analysts said on Sunday.

Experts also warned that Saturday’s crash, in which all 108 on board survived but the Boeing jet split in two, highlighted a “ticking time bomb” under the country’s aviation sector with a lack of experienced crew to meet fast-growing demand.

A little-known carrier launched 13 years ago with just one plane, Lion Air has struck two of the world’s largest aircraft orders in a staggering US$46 billion bet on Indonesia’s air transport boom.

France announced last month that the carrier had agreed to buy 234 medium-haul A320 jets worth US$23.8 billion from European aerospace giant Airbus.

It came after Lion Air astounded the industry with a US$22.4 billion agreement for 230 Boeing 737 airliners, inked in 2011 as a visiting US President Barack Obama looked on.

The company is betting big on the formidable expansion of air transport in Indonesia, which is experiencing passenger growth of around 20 per cent every year.

With 240 million people, Indonesia is the world’s fourth most populous nation, and embraces more than 17,000 islands scattered across 33 provinces.

But Saturday’s crash has heightened fears the plans are overambitious for an airline that already has a poor reputation, suffered a string of accidents, and is banned from EU and American skies over safety fears.

The Boeing 737-800 missed the runway entirely as it came into land at the airport on the resort island of Bali, slamming into the water and splitting in two, causing dozens of injuries but no fatalities.

Officials have given no indication as yet what may have caused the plane, which was brand new and delivered to Lion Air just last month, to ditch. There were 101 passengers and seven crew on board.

On Saturday, investigators said they had located one of the plane’s black boxes and were questioning the pilot.

“I do question whether Lion Air’s exponential growth... will put safety at risk,” Daniel Tsang, an analyst at Hong Kong-based consultancy Aspire Aviation, said.

“When an airline is too focused on growth and puts an emphasis on cutting costs, safety could be compromised.”

Tom Ballantyne, chief correspondent of Orient Aviation magazine, said: “There are always dangers with rapid expansion.

“Airlines have to be very careful when they grow so quickly, and Lion Air has to make absolutely sure that their safety systems are... improved as quickly as the growth of the fleet.”

Lion Air suffered a string of accidents between 2004 and 2006.

The worst was in December 2004, when at least 26 people died after one of its passenger planes skidded off the runway after landing and crashed in heavy rain in the central Indonesian city of Solo.

Wawan Mulyawan, an aviation expert at the University of Indonesia who specialises in crew health issues, said that since the plane was new, a cause of the accident could have been that the pilot was exhausted.

Pilots being rundown and overworked could become more of an issue for the country’s aviation sector as a whole, he said, as airlines expand rapidly and there are not enough qualified crew.

“Yesterday’s crash was the tip of the iceberg,” said Mulyawan. “If the number of pilots cannot grow as fast as the number of planes and flights, we can expect worse cases in the future. It’s a ticking time bomb.”

Lion Air has had problems with pilots in the past. It has been randomly drug testing its crews since several pilots were arrested in recent years for possession and consumption of crystal meth.

No one from Lion Air could be reached on Sunday to comment on whether the crash would affect their expansion strategy.

While the accident may have cast a shadow over the expansion plans of Lion Air, Indonesia’s first private airline founded in 1999 by brothers Kusnan and Rusdi Kirana, analysts doubted it would hold it back in the long term.

It has huge ambitions to expand its network from the current 72 routes, most of which are in Indonesia, and is betting on support from a burgeoning middle class which is keen to abandon travel by bus, ferry and train.

With both its recent mega-purchases in place, Lion Air would boast more than 600 aircraft by 2025, making it among the top ten of the world’s biggest airlines in terms of fleet size.

“Lion Air will have little difficulty in attracting middle class passengers continuously,” said Aspire Aviation’s Tsang.


AFP... 14/04/2013

[Globalstream]

Dear Colleagues,
As we heard a news that today one of our colleague got serious accident at Bali.
JT 904 / PK LKS / B 737-800 NG
Stretch : BDO-DPS
PIC : Capt. Mahlup Gozali (Local)
SIC : FO . Chirag Kalra (Indian)

Everyone onboard include active crew has been evacuate and no fatalities.
We highly appreciate with their good job and excellent professionalism.
Now we need all colleague to keep focus on your job and give service excellent to all passenger by giving a flight announcement with warm greetings. We need to keep all passenger feel safe to fly with Lion Air.
Last time kindly to remind you that always be aware of sudden windshear or any kind of weather phenomena that would result on speed drop and even worse aircraft sink especially on very short final position. Don't hesitate to put more additional thrust to disseminate this event and if abnormal thrust position reach it means the stabilized approach criteria has been breach and this is the alert for us to commence immediate GO AROUND. At this time REJECT LANDING Go Around procedure must be comply accordingly.
Finally my colleague I would like to say SAFETY IS COMES FROM OUR DICIPLINE. Always Keep alert and Have a safe flight.
God bless us.
Sincerely yours,


I will hold my personal judgements until a few more facts are known, however... Ehem, if that is really a letter from Lion's CP it seems to give credence to all the other remarkable stories emanating from this airline.

I'm incredulous anyone would want this airline on their CV- if it wasn't so sad it would be funny.

[awqward]

Well I think surat itu ada bohong.....bukan oleh CP

It looks made up...I deal with many many Indonesians and they all speak and write English far better than that....

[H. Hughes]

Check out this list:

PERFORMANCE REFERENCE HANDBOOK 737 (http://www.performance737.com/incidents.html)

Am I mistaken in thinking that Indonesia is overrepresented?

I particularly noticed Lions 14´Th and then 15´Th of February 2011 accidents. Same type plane, same airport and same accident two days in a row. Me thinks there is a problem here.......

[1stspotter]

Some quotes from this article
Investigators seek cause of new Boeing 737's crash into sea | Local & Regional | Seattle News, Weather, Sports, Breaking News | KOMO News (http://www.komonews.com/news/local/Investigators-probe-Boeing-737s-into-sea-in-Bali-202914941.html)

"The cabin crew had already announced that we would be landing shortly, and I was so excited when I saw the ocean getting closer, but suddenly ... it fell," he said.

The airline said it planned to suck the remaining fuel from the undamaged tanks in the plane's wings before towing it at high tide to avoid destroying the area's coral reefs.

1. a sudden fell
2. there was still fuel left

[pattern_is_full]

"I'm surprised. The airplane split in two upon impact," he said, estimating it was likely traveling close to 300 miles (483 kilometers) per hour.

I suspect he was assuming a pure water impact, and missed the fact that this aircraft landed in shallow water with a lot of obstructions (reefs and rocks) that would make for uneven forces on the fuselage, and thus a crack at a much lower speed.

Big difference between dropping an egg into water - and dropping an egg onto a knife-edge just below the water surface.

[despegue]

Comments from passengers and spotters are more often untrustworthy than usefull, although they do need to be taken into consideration

[fotoguzzi]

@BOAC

All good stuff! Have I missed anything? We should be able to get something out of that lot.

May or may not have called out a mayday.

[Sunnyjohn]

slamming into the water and splitting in two
Oh, aye? I rather think that if it had slammed into the water, it would have split up into somewhat more than two.

[DaveReidUK]

As is customary, the US NTSB, representing the state of manufacture, is sending a team to assist the Indonesian investigation.

[BOAC]

Well spotted, fg! A crucial factor.We are nearly there.

[wooski]

There was thick cloud around and the wind was quite strong. Then I looked up and the plane had not landed.

Schapelle Corby's boyfriend Ben Panangian was at plane crash scene, helped rescue passengers | News.com.au (http://mobile.news.com.au/travel/news/schapelle-corbys-boyfriend-ben-panangian-was-at-plane-crash-scene-helped-rescue-passengers/story-e6frfq80-1226620305655)

[training wheels]

Well I think surat itu ada bohong.....bukan oleh CP

It looks made up...I deal with many many Indonesians and they all speak and write English far better than that....

Having received numerous such memos (although but not from this airline), I can say it does sound authentic and is typical of the knee jerk reaction to safety from operators here when an accident or incident happens.

Their English is not good, but understandable .. and bit like your standard of bahasa as well, if I may say so ;) (If I may correct you, what you wrote should be "surat itu mungkin tipuan ... bukan dari CP"

[nippysweetie]

Reuters reporting that co-pilot lost sight of runway on finals, captain took controls then they hit 'wall of water' at between 400 and 200ft.

They opted to GA but aircraft 'started to sink uncontrollably'.

[Jet Jockey A4]

Some comments before the article...

1 - So I thought all co-pilots were not to fly the aircraft below 5000 feet?!

2 - It seems the captain took over the controls too late and perhaps at a too low of an altitude to recover.

3 - And the routine part of a "Go Around" is far from the truth IMHO.
Our check pilots report that "Go Arounds" are where a lot of pilots fail to perform the routine properly because it is one that is the least practice in real world flying. I for one, can't remember the last time I had to "go Around" in real world line flying.

Article by Tim Hepher

PARIS (Reuters) - The pilot whose Indonesian jet slumped into the sea while trying to land in Bali has described how he felt it "dragged" down by wind while he struggled to regain control, a person familiar with the matter said.

All 108 passengers and crew miraculously survived when the Boeing 737 passenger jet, operated by Indonesian budget carrier Lion Air, undershot the tourist island's main airport runway and belly-flopped in water on Saturday.

Officials stress it is too early to say what caused the incident, which is being investigated by Indonesian authorities with the assistance of U.S. crash investigators and Boeing.

But initial debriefings, witness comments and weather reports have focused attention on the possibility of "wind shear" or a downdraft from storm clouds known as a "microburst".

Although rare, experts say such violent and unpredictable gusts can leave even the most modern jet helpless if they are stronger than the plane's ability to fly out of trouble - with the critical moments before landing among the most vulnerable.

"If you have a downdraft which exceeds the performance of the plane, then even if you put on full thrust you will go downhill and you can't climb out," said Hugh Dibley, a former British Airways captain and expert on loss-of-control events.

The cause of the crash has potential implications for the reputation of one of the world's fastest-growing airlines, which is fighting to be removed from a European Union safety black list even as it buys record volumes of Airbus and Boeing jets.

According to initial pilot debriefings, details of which have been described to Reuters, flight JT-904 was on an eastwards approach to Bali's Ngurah Rai Airport at mid-afternoon on Saturday following a normal flight from Bandung, West Java.

The co-pilot, an Indian national with 2,000 hours of relevant flying experience, was in charge for the domestic trip, which was scheduled to last one hour and 40 minutes.

HEAVY RAIN

As the Lion Air plane was coming in to land, with an aircraft of national carrier Garuda following behind and another about to take off on the runway just ahead, the co-pilot lost sight of the runway as heavy rain drove across the windshield.

The captain, an Indonesian citizen with about 15,000 hours experience and an instructor's license, took the controls.

Between 400 and 200 feet, pilots described flying through a wall of water, according to the source. Bursts of heavy rainfall and lost visibility are not uncommon in the tropics but the aircraft's low height meant the crew had little time to react.

With no sight of the runway lights or markings, the captain decided to abort the landing and perform a "go around", a routine maneuver for which all pilots are well trained.

But the captain told officials afterwards that instead of climbing, the brand-new 737 started to sink uncontrollably.

From 200 feet, well-practiced routines unraveled quickly.

"The captain says he intended to go around but that he felt the aircraft dragged down by the wind; that is why he hit the sea," said the source, who was briefed on the crew's testimony.

"There was rain coming east to west; very heavy," the source said, asking not to be named because no one is authorized to speak publicly about the investigation while it is under way.

A passenger on board the jet painted a similar picture of an aircraft getting into difficulty only at the last minute.

"There was no sign at all it would fall but then suddenly it dropped into the water," Tantri Widiastuti, 60, told Metro TV.

Lion Air declined to comment on the cause of the crash.

WRITE-OFF

According to the Flight Safety Foundation, bulletins for pilots at around that time indicated a few storm clouds at 1,700 feet. A moderate wind blew from the south-southeast but flicked in a wide arc from east-southeast all the way to the west.

The source said there was no immediately obvious evidence of pilot or technical error but investigators will pore over the speed and other settings, as well as interactions between the pilots, to establish whether the crash could have been avoided.

Both pilots were given urine tests by the Indonesian police and were cleared for drugs and alcohol, the source said.

Neither pilot has been named.

According to Indonesian media reports, five Lion Air pilots have been arrested for drugs in the past two years, raising questions over whether drug abuse or overwork are widespread.

The airline's co-founder has denied this and told Reuters last year he was working closely with authorities to ensure Indonesia's tough drugs laws are obeyed.

Delivered in February, the aircraft itself had only had one technical problem: a landing light that had to be replaced.

Now lying broken-backed beneath a 15-foot (4.6-meter) sea-wall yards (meters) short of its destination, the $89-million Boeing has been written off. It was on lease from Dublin-based firm Avolon.

Pictures of the stricken jet lying in water and the fact that all on board survived brought back images of the "Miracle on the Hudson," in which an Airbus A320 ditched safely in New York after dramatically losing power due to a bird strike.

But industry experts say the suspected involvement of wind shear draws far more chilling parallels with the crash of a Delta Air Lines Lockheed Tristar while on approach to Dallas airport in 1985 that killed 134 passengers and crew.

Delta Flight 191 led to the creation of new warning systems and better procedures for dealing with low-level wind shear, or sudden changes of wind direction or speed.

According to Boeing, the 737-800, its most popular current model, is equipped with a "Predictive Windshear System". On approach, an aural warning says, "Go around, windshear ahead".

Nowadays, pilots agree the best strategy for dealing with possible wind shear is to avoid it entirely, said Dibley, who is a senior official at the UK's Royal Aeronautical Society.

But if the "wind shear" warning blares out, the automatic response is to cancel the landing and go around again, he said.

DELICATE BALANCE

Pilots can sometimes prepare for risks, such as a possible loss of the right sort of wind on landing, by keeping a buffer of extra speed to help them get out of trouble, he said. It is a delicate balance as too much speed could make the jet overrun, which in the case of Bali means hitting a road or yet more sea.

"If your speed is too slow and you hit a downdraft you will just sink. So one question is how much extra air speed the aircraft was carrying," Dibley said.

There was no immediate information on what cockpit signals were available to the crew, how fast the Lion Air jet was flying or what sort of scheduling roster the crew had been flying.

Founded by two brothers and travel entrepreneurs, Lion Air has been growing at a record pace to keep up with one of the region's star economies. Last month, it signed a deal with Europe's Airbus for 234 passenger jets worth $24 billion. Two years ago, it signed a deal with Boeing for 230 planes.

At the same time, however, Indonesia has been struggling to improve its civil air safety after a string of deadly accidents.

In 2007, Lion Air was among a number of Indonesian airlines banned by the EU for lax safety standards.

The ban was progressively lifted, starting in 2009, but although it has had one fatal accident, Lion Air remains on the EU's banned list - a predicament it has dismissed as unfair.

(Additional reporting by Neil Chatterjee, Andjarsari Paramaditha and Chris Nusatya; Editing by Eric Walsh)

[truckflyer]

First Indian national with 2000 hours experience, maybe!

First hand experience, which I saw from a European TRTO, they had contracts / have contracts, where they train Indians who come trough an Indian agency. They pay approx. 50.000 Euro, this includes TR and placement with Lion Air, where they are paid, can't recall what they told me what they would be paid, but it was close to "peanuts"!

During my short time I observed around 40 Indian pilots doing this training, and I did overhear several conversations by the trainers, telling the students what to expect with regards to CRM!
CRM would be more or less non-existent, compared to what we would expect in Europe, and they would be a little more than a flap operator, however I did see the instructors was trying to give these young Indian pilots some positive advice to try to improve this mindset, that exists in these countries!

So back to the 2000 hour FO, how much does these 2000 hours really mean, if the FO has not been allowed to develop his own skills!
It would not surprise me if he was from this TRTO, as they was constantly getting fed pilots from India for Lion Air!

[hotnhigh]

Did they push toga or just followed the flight directors into the sea?

[nippysweetie]

One thing we can be sure of is that the aircraft did, indeed, sink. Twice.

[Clear_Prop]

Thanks for posting that, Jet Jockey.

That article almost had me convinced until I read "said the spokesman who had been briefed on the pilots' testimonies" - by the CEO and his damage limitation henchmen no doubt, who likely haven't even heard the pilots' testimonies!

[despegue]

Flaps at ditching look like 40 or 30. In a go-around flaps are set to 15 in normal circumstances, exept in windshear, where ne does not change configuration.
The aircraft was probably light due to the light load so performance should have been very good.

[NSEU]

The airline said it planned to suck the remaining fuel from the undamaged tanks in the plane's wings before towing it at high tide to avoid destroying the area's coral reefs.

....
2. there was still fuel left

There will always be a significant amount of fuel in the tanks which cannot be accessed by the pumps. For maintenance purposes, fuel tanks have to be completely drained using sump drains.

Auto Relight.

--------------------------------------------------------------------------------
According to Mr Boeings book "whenever the EECs detect a flame-out".......

At less than 500' on the approach it's a bit late for the AUTOMATICS to start attempting to relight don'tya think? :ugh:

Depending on the engine type, Autorelight has the ability to relight an engine before you even realise you've had a flameout. The system looks at engine deceleration and is smart enough to know the difference between slamming the thrust levers to idle and flameout.

[bubbers44]

I wonder what the radar display showed on their approach. We have all done low altitude missed approaches at DH with no runway but radar usually lets you know if you should attempt the approach quite easily. The cell they encountered would have been quite visible on radar in my opinion.

[Lookleft]

What is beyond doubt is that the aircraft was in a low energy state when it hit the water. This is an extract from an incident report into a similar 737 incident in Australia

Had the aircraft encountered those conditions just before the go-around was initiated,the time taken for the crew to recognise and then react to the situation may have resulted in a more serious outcome. At that stage, the aircraft would have been at an altitude of about 200 feet, with the engines operating at a relatively low thrust setting,and with the landing gear and wing flaps in the landing configuration. Entry into a 3,300 ft/min downdraft at that point would have given the crew less than 5 seconds to execute the prescribed B737 windshear recovery manoeuvre to prevent collision with the ground.(ATSB 200100213)

Could be the Lion Air crew started their GA just a bit too late. The low energy state could have been the result of a high thrust setting reducing the sink rate to a survivable rate when it hit the water.

[bubbers44]

Count out 5 seconds. Maybe half a second to initiate the go around could be done by any competent pilot.

[sevenstrokeroll]

bubbers makes a good point about wx radar...and as we know, there is a bit of an art to tilt esp at low altitudes.

as to windshear recovery...we are almost always at a low energy state as we approach the runway. five seconds is a LONG TIME...throttles to firewall pitch to 15 and hang in there.

just a marginal wx operation? visual deception or mis cue, whichever you like to call it.

and the more gadgets, the more we will repeat accidents in the twilight zone of pilot judgement...

[sevenstrokeroll]

one thing that has not been mentioned is pinpoint precip in such high volumes that lift is litteraly washed from the wings...studied by NASA for some time.

I'd also like to remind some of the DC9 crashin KCLT in the early 90's...right around the time of the OJ simpson stuff.

crew went around in heavy rain ( I was there, on the ground...worst stuff I've ever seen...sky was GREEN) did not go to firewall thrust or even full go around thrust...no warning of rain from ATC...seq report back then didn't even have rain on it.

part of the problem, besides the thrust issue, was loss of visual ref and miscues...plane crashed...some 30 dead.

we also learned that the windshear gadget on the 9 wouldn't work in a bank over 15 degrees...

we shall see...but if things are bad and you don't have one hand on the throttles ready to JAM EM FORWARD MANUALLY, you might have lots of explaining to do.


oh...and there was an early 737-300 series that lost both engines in heavy rain, TACA, they landed on a leveee....maybe loss of thrust due to heavy rain...we shall see.

[GBV]

Very similar to One-Two Go crash in Phuket. Probably pilots lost visual contact with runway didn't know what to do or how to conduct a proper go-around and just crashed into the sea.

[bubbers44]

Us old timers were spring loaded to go around if 200 ft found us still in the clouds. The go around was simple, max power with pitch to 15 degrees reduce flaps, positive rate gear up. The latest Air France 777 situation where they tried to go around around at 330 ft but descended to 87 ft before climbing was I think another example of automation dependency. They depend too much on the autopilot and button pushing to handle things. The annunciator went from cat III to cat II with an alert. I guess they didn't push the right button.

[Centaurus]

Assuming the pilot decided to go around from 200 ft. unless he immediately manually opens up to go-around thrust while simultaneously rotating the aircraft to up to 15 degrees body angle up, then chances are the aircraft will continue to descend during the attempted manoeuvre until the rate of descent is arrested by pointing up to go up.

Many very low altitude go-arounds we see during simulator training often catch the crew by surprise if they were not expecting it, with the result in the pilot pitching tentatively to only 10 degrees and that delays the climb out for a few seconds. Although selection of TOGA is mandatory in a go-around that low, if the AT is already switched off as it should be in the non-precision approach on manual flight (see Boeing FCTM) then the pilot must aggressively select the thrust levers to open. The FD will initially go to approximately 15 degrees with TOGA, but the main point is the pilot flying has to be "aggressive" in his power and pitch up.

Any hesitation in decision making at that very low altitude and any hesitation in actually carrying out the physical handling side of the manoeuvre (for whatever reason), will most likely result in a descent of 100-200 ft before finally getting away from the ground. At that altitude (200 ft) that the Lion Air 737 was at, and forward vis was drastically reduced due heavy rain on the windcreen, it means the pilot would have to be very good at basic manual instrument flying. And that now becomes another story...

[Lookleft]

one thing that has not been mentioned is pinpoint precip in such high volumes that lift is litteraly washed from the wings...studied by NASA for some time.

Have look at the report I quoted. Its mentioned in there. The crew may not have encountered a TS but the volume of water may have been enough to reduce the performance of the aircraft such that the GA commenced at a low level was not going to prevent the impact with the water.

[bubbers44]

Centaurus, nobody in my generation of pilots would descend more than 30 ft below 200 at missed approach because we didn't need an autopilot, we just hand flew most of our approaches. We would rather hand fly it than take our chances with the AP. None of us would have landed in the water using radar and hand flying skills. Radar will tell you where the cells are low level if you point it up over 5 degrees and flying skills means you don't have to look down to find a button to push. Automation is great but it makes a lot of pilots forget how to fly. Most of the time because of the airline SOPs not letting them because of their low time. I thought Air France was teaching manual flying skills again, guess not. Not in their budget?

[Hardbutt]

Bali Runway 09 VOR approach only. Minimums 470 feet. :hmm:

[Hardbutt]

Another case of 'Automatiocitis' methinks.:hmm:

[Up-into-the-air]

I have been reading this with interest and note a comment from Smiling Monkey

And how is this any different from all of the other accident/incidents discussed on PPRuNe in the past?

Leave the the investigation to the professional investigators; wait for the official report to be released, and only after that, can we expect to learn from what has happened.

In the mean time, we continue to speculate what happened.Please have a look at the absolute mess Australia's casa and atsb have made with the Westwind ditching at Norfolk Island in 2009. The Senate inquiry is riveting reading.

A summary is at: http://www.pprune.org/australia-new-zealand-pacific/468048-senate-inquiry-hearing-program-4th-nov-2011-a-75.html#post7792224

and more information at: 2012 ? PelAir [Norfolk Island] | Assistance to the Aviation Industry (http://vocasupport.com/?page_id=83)

[bubbers44]

It doesn't matter what minimums were but why did they land in the water? Did they look at their radar? The DFW windshear crash was really emphasized in our training of how to avoid a repeat of that. Going into San Salvador one day I held an extra circuit in holding when minimums came back up to let things stabilize. Now I had a nice easy approach with a headwind instead of a quartering tailwind. I did all my hero stuff in the 20's and 30's, not in my 50's.

[framer]

And that's the stuff ( attitude/ wisdom/ practical examples) we need in our airlines. Good example Bubber.

[Lookleft]

It doesn't matter what minimums were but why did they land in the water?


Possibly by the time they realised that they had lost visual reference and needed to GA the laws of physics and aerodynamics meant a water landing was inevitable.

I would guess that this was a different scenario to DFW as they weren't unstable for most of the approach. I would also put forward a suggestion that a windshear warning wasn't triggered as it would have been at DFW.

Most readers of this thread forum would not be in the slightest bit interested in the Australian regulator/investigator.

[Loose rivets]

. . . but the volume of water may have been enough to reduce the performance of the aircraft such that the GA commenced at a low level was not going to prevent the impact with the water.

Brings back a few butt-clenching memories. Last minute and very unexpected wall of water, and a very real feeling of ground speed being diminished in the deluge.

seven's post. "Lift literally being washed off the wings." [Sic] is also a good description of how it feels.

[TRF4EVR]

Oh, for the Love of, uh, "the deity of your choice"...if the thing was working properly and wasn't out of gas, they screwed the pooch. "The rain destroyed the lift!" I'd laugh if it didn't make me want to cry. How do you reckon millions of flights land in the dreaded RAIN every day? The largesse of Jupiter? I've flown through storms I'd have drowned in without the windshield, and the wings never magically stopped flying. No doubt the Feds will come out with an exhortation to avoid all rain in the future. Lulz.

[justanotherflyer]

All good stuff! Have I missed anything?

May have been flying too fast/flying too slow/had too much energy/had too little energy.

[IndoLion]

Its the actual email sent from the Cheif pilot (Destyo Usodo) to all flight crew.
:ok:

[A4]

Does the 738 have an similar function to the Airbus GS Mini? For those unfamiliar, the airbus system is designed to ensure the aircraft maintains a minimum groundspeed during gusty approaches. Consider the following. You have a target approach speed of 145kts and autothrust/autothrottle is engaged. You encounter a positive shear of 15 kts so your IAS now increases to 160kts and your groundspeed reduces to 130kts. With a conventional system, because you're now above your target approach speed the thrust will be REDUCED to achieve target. The shear then ceases and your IAS and GS reduce accordingly - however , you've already lost an additional 5-10kts due to trying to reduce to your original target approach speed so you're now slow, with reduced/idle thrust AND reducing energy. Unless the thrust is applied appropriately a sink could develop very quickly.

On the Bus, when the gust is encountered your target approach speed actually INCREASES (to maintain GS) which requires thrust to be maintained or increased. As the gust recedes, and target speed slowly reduces, thrust is adjusted SLOWLY back to what's required. This is a dynamic function and results in the target approach speed sliding up and down the speed scale during the approach - but it maintains the aircraft energy and keeps the engines spooled to avoid a low energy/low thrust scenario.

So, with a rapid sink into the sea, there is a possibility of positive shear (gust front with the heavy rain encounter) with an associated thrust response as described above leading to an unrecoverable situation.

Can any Boeing drivers confirm the systems or procedures (increased approach speed?) required in such conditions.

A4

[IndoLion]

No, the B737NG does not have the sort of function that you mentioned above. Though there is something similar, A/T in ARM mode. But Lion SOPs dictate the disconnection of A/T when the aircraft is being manually flown on landing.:ok:

[DaveReidUK]

The AD referred to in earlier posts was preceded by an NPRM in September 2012, so clearly isn't a reaction to the Lion Air accident.

Although the AD applies to all 737NGs, Boeing have stated that stabilizer attachment pins delivered after August 2008 are not suspected of having incorrectly applied wear and corrosion protective surface coating.

[thomasfo]

Here are more pictures, also from inside. The tail has been taken/broken completely off now.

Må kappe opp Lion Air-flyet - VG Nett om Indonesia (http://www.vg.no/nyheter/utenriks/artikkel.php?artid=10109281)

[IFixPlanes]

The aircraft in Bali has the line number 4350.
The AD points to a rear spar attach pin installed on line number 1 to 3534.
And these aircrafts have to be inspected prior to the accumulation of 56,000 total flight cycles on the pin, or within 3,000 flight cycles after the effective date of the AD, whichever occurs later.

[philipat]

Again, just FWIW, I live in Bali about 4 miles East of the 27 DPS threshold. On the day of the accident there were very light breezes from the SE and some localised rain showers but nothing heavy. There was NO TS activity. Given the prevailing winds, anything over to the West, would normally have come through Sanur earlier. And it did not. It would seem to me that the conditions for windshear were simply NOT present. Of course, we need to wait and see and I will, of course, stand to be corrected.

[HalloweenJack]

would appear the media are paying attention to the speculation within this thread....

[justanotherflyer]

would appear the media are paying attention to the speculation within this thread....

And no doubt will speculate about the speculation. 'Twere ever thus.

Plenty of meat for them in this trenchant analysis:

An early probe by the National Committee for Transportation Safety (KNKT) points to undershooting the runway as the cause of a Lion Air plane that landed in the sea on Saturday, an investigator said on Sunday.

“The possible cause is undershoot. We are still looking at why the plane undershot the runway,” Masruri, head of the KNKT’s air transport accidents research department, told reporters.




.

[Capn Bloggs]

given the met, my bet is a wet microburst that they could not have seen, nor would radar have spotted it, (unless pointed straight up), because it came down on top of them.
These things don't appear from nowhere. If it did smash the aeroplane into the water, it would have been plainly visible on the radar with moderate up-tilt as the approach was started, around the IAF.

[Cereal Expert]

Could anyone suggest what the tail wind maximum allowance is for a B738 given the circumstances, and can they land on this runway from the opposite end to 09? Earlier and apparently credible local weather reports on this thread have suggested that the eastern end approach was as clean as a whistle with light winds. Forgive me for being a layman, but I'm curious as to what it actually takes to bring about a runway change or actually close an airport.

[fireflybob]

If microburst is a possible contributory cause, one presumes the crew would be trained and practised in the Windshear Escape Maneuver?

I appreciate that a severe microburst may compromise the ability of the aircraft to climb with ramifications when at low level.

[moolooman]

Hi, I'm a journalist. We always monitor this forum, its the best way to figure out what is happening. Just wondering if any of the professional pilots here would be interested in helping with a story about Lion?

Totally off record and confidential. PM if you can help.

[Jet Jockey A4]

to moolooman

Anything said about this accident without the information provided by the "black boxes" from the aircraft, would IMHO at the very least be speculation and this from anyone wishing to comment on the crash.

[B737900er]

Confidential and off the record? Well what ever we tell you, you will twist and make more exciting to sell the story like all journalists.

What you need to know about LNI well...
They have more money than sense.
Lots of corruption
The reason why they believe theyre blacklisted is because they don't have Airbus (hense the huge order).

It's a man boy airline, the captain is always right. (culture thing)
Biggest P2f operator known to man.

Has a huge influx of Indian students, who are under investigation from Lion air and DGCA due to false hours and/or licenses.

Cant take critism to well and its always somebody else's fault.

The list goes on!

Without disrespecting anyone, but the Far East culture and Aviation doesn't mix to well. Usually due to a break down of CRM or 'don't fix it unless its broken' mentality.

[Jet Jockey A4]

To add to B737900er's post and strictly staying on the flying side of things (btw, his points are very valid ones)...

It usually takes 3 broken links in a chain for an accident to happen. The following could be contributing factors to the crash...

- Bad weather (thunderstorm, windshear/microburst).

- Mechanical problems (always a possibility).

- Mediocre flying skills with lack of experience.

- Fitness of the crew (hours on duty).

- And finally, bad airmanship (poor decision making and/or bad judgement).

[de facto]

Weather or no weather,non precision or precision approach,unless both engines failed or any other catastrophic failure,the Captain::mad::mad: up and will/should never be Captain of an airliner again.
Just lucky no pax were injured.

[BOAC]

Just lucky no pax were injured. - according to the BBC, 45 were?

[jetjockey696]

Indonesian investigators Monday began retrieving the wreck of a Lion Air plane that crashed at Bali's airport, as accounts emerged of a freak storm that could have caused the accident.

The Boeing 737-800 missed the runway as it came in to land on Saturday, slamming into the sea and splitting in two. Dozens of the 108 people on board were injured, but there were no fatalities.

After the plane hit the water, terrified passengers swam to shore as police came to their aid in rubber dinghies.

Government officials and the airline said at the time of the crash that the weather had been fine.
But on Monday, transport ministry official Herry Bakti said the plane had been traveling through dense cloud at the time of the incident and one passenger told how the aircraft became engulfed in torrential rain.

French businessman Jean Grandy, 49, one of four foreigners on the plane, said that the flight from the city of Bandung in West Java had appeared to be landing smoothly.

"The final approach was fine," he told AFP.

"Then suddenly, a cloud enveloped us. Torrents of water were pouring on us, it was an enormous downpour. It only lasted two, three minutes.

"It was almost as if it was night, even though the sun had been shining just before," said Grandy.

The Frenchman, who owns a shoe factory in Indonesia and lives in Bali, said it was an "extraordinary phenomenon" that could have happened to any plane — and that he planned to fly on Lion Air again on Wednesday.

His testimony supported the views of some analysts who said that as the plane was new, a freak weather incident may have caused the crash of the Boeing 737-800 which was delivered to Lion Air only last month.

Tom Ballantyne, chief correspondent of Orient Aviation magazine, said the accident could have been caused by a change in wind direction and speed between different altitudes, or a strong downdraft from storm clouds.

"If that hit the aircraft when it was on final approach, there is the likelihood the pilots would not have had time to recover," he told AFP.

The Indonesian pilot, Mahlup Gozali, who had more than 10,000 flying hours, and the Indian co-pilot, Chiraq Carla, tested negative for drugs and alcohol in preliminary tests, a transport ministry spokesman said.

Divers were on Monday drilling a hole in the tail of the wrecked plane to retrieve the cockpit voice recorder located there, and pulling seats and other small pieces of small debris out of the water to take them ashore.

Salvage teams will be lifting the body of the plane in three parts, said Bali airport general manager Purwanto.

The tail will be lifted using a crane later Monday, and the whole operation should take two to three days to complete, said Purwanto, who like many Indonesians goes by one name.

The low-budget carrier launched 13 years ago with just one plane, Lion Air has struck two of the world's largest aircraft orders in a staggering $46 billion bet on Indonesia's air transport boom.

France announced last month that the airline had agreed to buy 234 medium-haul A320 jets worth $23.8 billion from European aerospace giant Airbus.

Lion Air also astounded the industry with a $22.4 billion agreement for 230 Boeing 737 airliners, inked in 2011.

Saturday's crash has heightened fears the plans are overambitious for an airline that already has a poor reputation, suffered a string of accidents, and is banned from EU and American skies over safety fears.

Lion Air has had problems with pilots in the past. It has been randomly drug testing its crews since several pilots were arrested in recent years for possession and consumption of crystal meth.

Indonesia, which relies heavily on air transport to connect its sprawling archipelago of more than 17,000 islands, has one of Asia's worst aviation safety records. The Bali crash was the nation's fourth accident since the start of 2012.

In May last year, a Sukhoi jet, post-Soviet Russia's first passenger plane, slammed into a volcano on the outskirts of Jakarta during a demonstration flight for prospective buyers, killing all 45 on board.

Agence France-Presse April 15, 2013

[overthewing]

I wonder why the slides didn't deploy?

[Capn Bloggs]

I wonder why the slides didn't deploy?
Which slides didn't deploy?

[Eastwest Loco]

For what it's worth I have been told by a friend within Indo aviation that the first call a pilot will get after a go around or diversion is from the CEO telling them they are out of a job.

The MD hull loss at Solo is a case in point. Landed but long and went agricultural.

There was a GA DC9 extreme heavy land that bananad the fuselage many years ago in the era when if daddy was a general you could get a seat flying for them that was blamed on microburst/windshear in conditions that just could not support either. Savin face. Douglas dudes came out to inspect the aeroplane for repair and shook heads. It was towed off into the palms around the runway and is most likely still there.

Garuda has excorcised the culture but it still lives in the LCCs. The GA 737 bender at Jogjag was the turning point and they are now world class.

The others however, the Lion, Mandala, Express Air and worst of all Merpati operations are ones I would not even taxi on.

As to what happened one can only assume. To mind comes under glide path and can't get power back on in time, ran out of bang wasser, screwed approach and wasn't willing to lose face and go around or maybe the noise just stopped because of a mech issue.

One can only imagine the dismay of surfers on Airport Lefts (the surf break you see in the background of the pics) when a 738 dropped in on them.

No casualties - good result to a bad bender.

Best all

EWL

[MrMachfivepointfive]

Freak weather? Yeah... right.
Divers cutting into the wreck for the recorders... In 6 inches of water? Yeah... right.
What about the wake turbulence of the fire spitting dragon spotted by witnesses?
Why can't we name the elephant in the room? Two jokers who should not have been anywhere close to any airplane ever trashed a brand new Boeing in perfect Bali holiday conditions. Just lucky that they did not hit that sea wall.

Yeah ... Blast me for not being politically correct and pre-empting the final report. But a donkey is a donkey and not a short furred mammal with four hoofs.

[Capn Bloggs]

Ventus 45, I hear what you're saying. I just don't believe that the cloud that generated the hypothesised microburst formed, from nothing to one could drop such a MB, in the few minutes from the IAF.

[BOAC]

Aha! Obviously a poster with inside information.

Need to add
"Two jokers who should not have been anywhere close to any airplane" to post #283:ok:

I would think moolooman has more than enough to go on.

[flash8]

With that bastion of credibility the Indonesian NTSC at the helm (authors of the esteemed Silk Air 'report') I await with baited breath the conclusions.

As Jet Jokey stated quite
- Bad weather (thunderstorm, windshear/microburst).

- Mechanical problems (always a possibility).

- Mediocre flying skills with lack of experience.

- Fitness of the crew (hours on duty).

- And finally, bad airmanship (poor decision making and/or bad judgement).

I know what three I'd bet on.

[overthewing]

Which slides didn't deploy?

According to this report Schapelle Corby's boyfriend Ben Panangian was at plane crash scene, helped rescue passengers | News.com.au (http://mobile.news.com.au/travel/news/schapelle-corbys-boyfriend-ben-panangian-was-at-plane-crash-scene-helped-rescue-passengers/story-e6frfq80-1226620305655)

"She told News Limited she thought she was going to drown because almost immediately after impact, water started rushing in from the floor of the plane.

Her seat was near where it broke in two.

At first she struggled to free herself and was bleeding heavily from her right leg, but eventually she got out.

She explained none of the rubber slides meant to open after a crash landing had done so. Passengers were forced to jump into the water and swim to safety. "

Some photos suggest forward starboard slide /chute deployed, but I haven't seen evidence of the other three. Passenger descriptions of being rescued in rubber dinghies seem to refer to actual rubber dinghies being used by local surfers.

[overthewing]

Schapelle Corby is currently in prison, so that was a good trick

The 'she' referred to is not Ms Corby, whoever that might be; her name is only mentioned because her boyfriend was one of the rescuers.

[lederhosen]

It will be interesting to see how much thrust was being produced just prior to what rumours suggest was an unintentional ditching. I am sure the investigators will be looking hard at this. As Boeing says 'Severe windshear may exceed the performance of the AFDS system' and the Delta Tristar crash is a good example of the extreme effect of a microburst. If for some reason thrust was too slow in increasing (water ingestion/ human error etc.) this combined with a downdraught could have contributed to the aircraft's failure to climb. It is nearly miraculous that no one was killed.

[FlightPathOBN]

Does the airport have a low level wind shear alert system?

Wind shear doesnt only occur from a microburst.

[bubbers44]

This focus on microburst doesn't make any sense. The Bali resident who reported no significant weather 2 miles away makes the microburst thing pure conjecture, no facts. The black boxes are being read now so why not wait and see? Let the journalist wait too. Don't feed him bogus info.

[FlightPathOBN]

sad looking 738...

http://www.straitstimes.com/sites/straitstimes.com/files/LionPlane1504e.jpg

[Warped Wings]

If windshear was not a factor and the aircraft was serviceable, how else did the aircraft land short of the airfield?

How about an incorrect QNH set putting the aircraft below profile
Crew not visual with the runway due to cloud / rain showers prior to the field
Heavy shower encountered at short final and crew persist with approach
Aircraft flys itself into the water
Only clue of ground / water proximity would come from the rad alt EGPWS calls

[JPJP]

If the Radar altitude track is accurate they were already below minimums for the VOR approach to 09. They were also 100 feet low on glide path if performing the approach using IAN (Integrated Approach Navigation) . At 1 mile from the runway that puts them at 200 feet AMSL.

Below minimums, already low and they lose sight of the runway in reported heavy rain; An immediate Go Around is required. Not the reported transfer of controls from the F.O. to the Captain. At 200 feet and descending they have 15 seconds before they hit the water.

[minimaman]

reuters account:

As the Lion Air plane was coming in to land, with an aircraft of national carrier Garuda following behind and another about to take off on the runway just ahead, the co-pilot lost sight of the runway as heavy rain drove across the windshield.

The captain, an Indonesian citizen with about 15,000 hours experience and an instructor's license, took the controls.

Between 400 and 200 feet (122 and 61 metres), pilots described flying through a wall of water, according to the source. Bursts of heavy rainfall and lost visibility are not uncommon in the tropics but the aircraft's low height meant the crew had little time to react.

With no sight of the runway lights or markings, the captain decided to abort the landing and perform a "go around", a routine manoeuvre for which all pilots are well trained.

But the captain told officials afterwards that instead of climbing, the brand-new 737 started to sink uncontrollably.

From 200 feet, well-practised routines unravelled quickly.

"The captain says he intended to go around but that he felt the aircraft dragged down by the wind; that is why he hit the sea," said the source, who was briefed on the crew's testimony.

"There was rain coming east to west; very heavy," the source said, asking not to be named because no one is authorized to speak publicly about the investigation while it is under way.

full article:

Exclusive - Lion Air crash pilot felt jet dragged from sky | Reuters (http://uk.reuters.com/article/2013/04/14/uk-indonesia-plane-idUKBRE93D0D520130414)

[MrMachfivepointfive]

How about an incorrect QNH set putting the aircraft below profile
Crew not visual with the runway due to cloud / rain showers prior to the field
Heavy shower encountered at short final, crew continues below the minima
Aircraft fly itself into the water
Are you serious, or are you a reporter of the Herald Sun munching up key words? Book yourself some C152 dual time. It will answer all your questions.

[lederhosen]

Certainly the recorded thrust lever angle at various stages would be interesting to know.

[despegue]

NO professional crew will continue below minima on a VOR approach when the runway is not in sight, even if QNH was forgotten to be set or set incorrectly. ( radio altimeter is still there as crosscheck by the way!).

It is simply not done to give controls to the other crewmember when losing sight of the runway. YOU GO AROUND. That is basic stuff, Surely not even airlines like Lionair who use slavery pilots ( you get that Media? Yes, slave pilots who pay 50000us$ to fly your family, these includes even Captains!!!) are that lacking in professionalism and training to not have any standard on the flightdeck?
There Must have been an alignment of all holes in the swiss cheese like with any accident.

[FlightPathOBN]

Now we know that a 738 can land just as safely in the water as an A320!

(sorry Sully, at least the 320 didnt break up)

[Mareklug]

(I'm not getting any traction in the regional thread; this place looks busier, forgive the duplication.)

Is the following statement true?

"This is the first time in history that a full-sized passenger jet crash-landed directly in the open sea without fatalities."

And if so, how would one go about documenting it with a reliable source (book, trade magazine article, officially published statistics, database result)?

[Loose rivets]

Oh, for the Love of, uh, "the deity of your choice"...if the thing was working properly and wasn't out of gas, they screwed the pooch. "The rain destroyed the lift!" I'd laugh if it didn't make me want to cry. How do you reckon millions of flights land in the dreaded RAIN every day? The largesse of Jupiter? I've flown through storms I'd have drowned in without the windshield, and the wings never magically stopped flying. No doubt the Feds will come out with an exhortation to avoid all rain in the future. Lulz.

Not the main thrust of my post, but I am still mindful of seven's comment.

You seem to discount the NASA research mentioned? This is specifically a low altitude/last minutes problem. When you consider the mass of the rainwater, it seems there is a time when it can't be accelerated appropriately over the upper surface, suddenly and severely disrupting lift.

My main point was how the groundspeed might have been affected.

It was never something I had to calculate or really even think about, but then, I was in old iron and the power levers were always in my hand. They would somehow move by the accelerative forces on my backside, long before any medium-term and meaningful change of airspeed was registered. A totally mysterious process, but one that requires some years of being in touch with real mechanisms.

Edit to ask: Do modern auto-throttle systems have accelerative inputs to predict responses?




.

[golfyankeesierra]

Now we know that a 738 can land just as safely in the water as an A320!
Irony or are you serious?
It broke in two, if it wasn't sitting on the reef it would probably have sunk to the bottom with half of the pax in it.
Might have broken in two because of the reef but we will never know.
But it sure is no proof that "a 738 can land just as safely in the water as an A320!"

At first she struggled to free herself and was bleeding heavily from her right leg, but eventually she got out.

She explained none of the rubber slides meant to open after a crash landing had done so. Passengers were forced to jump into the water and swim to safety.
I remember that on a 738 the aft doors should not be opened in case of ditching. So according to Boeing only overwing exits (which have no slides) and slides at fwd doors should be used.
Looking at the photo's the RH fwd door had a deployed slide, so much for eyewitness accounts...

[VP TAA]

This not the first. A DC8 went in to San Francisco Bay, in 1968 ,in landing configuration. No fatalities . Aircraft was flying again in less than a year
VP TAA

[grimmrad]

SLF with interest in flying here (too bad that we need this disclaimer here now but happy to do it):

The engines: does the damage on the leading edge of the right wing mean they ripped off upon impact (reef close to surface explaining it)?

http://www.straitstimes.com/sites/straitstimes.com/files/LionPlane1504e.jpg

[Tiennetti]

No, if you look to images from yesterday, the slats are not damaged
The wings looks perfect, apart the broken winglet

This damage we can see here is probably done by the aircraft impacting those rocks while moved by the waves

[jetjockey696]

The Ministry of Transportation is to audit the management of Lion Air following plane crash occurred on April 13 near Bali`s airport, Minister E.E. Mangindaan said here on Monday.

"We will conduct special audit for Lion Air. Among factors that will be checked are the condition of all aircraft owned by the company, plane maintenance system and airline management," Indonesia's Antara quoted the minister as saying.

He added the ministry will closely monitor every Lion Air flight to prevent similar crash to recur. As to the pilot and co-pilot of the ill-fated plane that crashed in Bali, both of them are grounded for two weeks to facilitate investigation.

Lion Air management itself has stated its willingness to provide compensation for all passengers of the plane. Investigation on the cause of the accident is still on going.

Lion Air flight JT904 from Bandung (West Java province) to Denpasar (Bali) crashed at sea last Saturday when it was to land at Bali airport.

"The plane with seven crew members was carrying 101 passengers from Bandung, West Java, to Denpasar when it undershot the runway," said Lion Air`s Director General Edward Sirait.

No report on casualties from the incident.


BERNAMA......

[Mareklug]

"at open sea" -- San Francisco Bay does not qualify, I don't think, and neither do rivers (NYC, St. Petersburgh, Yogoharta -- 1 fatality) or Hong Kong (aircraft touched down 2/3rd down the runway and overshot into the water, also not open sea.

So... a first?

[moolooman]

Thank you very much for your help guys, great responses. Interview done.

Cheers.

[DaveReidUK]

The engines: does the damage on the leading edge of the right wing mean they ripped off upon impact (reef close to surface explaining it)?The photos linked from one of the early posts, taken shortly after the event, appear to show that at least one, if not both, pylons and engines have detached from the wing. All will no doubt be revealed when they lift the wreck out of the water.

Whether they hit the reef or not is probably academic - hitting the water alone, at that speed, would be like hitting concrete.

Same thing happened to one of the engines on the Hudson A320, it ended up on the river bed.

[Passenger 389]

re: ditching in "open ocean"

What about Pan Am Flight 6 (ditched in the Pacific on Oct 16, 1956). Didn't all 31 aboard survive?

ed. Was not a "jet" however, but a Boeing 377 Stratocruiser.

[smiling monkey]

Passenger descriptions of being rescued in rubber dinghies seem to refer to actual rubber dinghies being used by local surfers.

Surely the weather couldn't have been that bad if there were surfers surfing nearby? :rolleyes:

[Toruk Macto]

Taking over from the F/O and hearing you have control can cause a problem at such a critical stage .
The cpt should be ready but if your sitting there thinking the other guy is visual or handling it ok when he says I got no idea its all yours . Could be a factor . Better the F/O just go around than hand over .

[sevenstrokeroll]

with reefs nearby, was it really open sea?

still, the best ditching was the JAL DC8 KSFO in 68...if you can use the plane again...that's pretty darn good.

and the funny thing about this ditching (SFO) is that they didn't know they were ditching...

[bubbers44]

As I recall they had an American FE that said they were too low but the captain ignored because of cultural differences not allowing a subordinate to tell the captain what to do.

[bubbers44]

I had to take control from my chief pilot once in a 4 engine corporate jet once, Jetstar, because in a driving rainstorm with max crosswind he was landing half way down a 6500 ft runway so went around. I knew I was fired but to my surprise he thanked me. Sometimes you have to just survive and just find another job. Much better than being dead.

[sevenstrokeroll]

there are pilots who are amazingly attuned, so totally ONE with the plane that they are flying at a whole different level than those pilots who are sort of just along for the ride.

the increased automation of planes is reducing this "ONE NESS" with the plane.

good for you bubbers with that jetstar thing...which airport?

[bubbers44]

Lafayette, LA I think. I guessed at the runway length, just knew it was longer than SNA. The chief wouldn't let me put on the wipers because they were too noisy for the customers. I said I can't see because the wipers were off at MDA he said turn them on and we were approaching the threshold at 400 feet so said go around and pushed the throttles to max when he was going to landing flaps and idle power then I went to go around and changed flaps. I have never had anybody do that to me but am happy I did it that night.

[bubbers44]

SSR, we must have some young pilots out there that can do it too. Look at the talented 21 year old fighter and bomber pilots we had in WWII. I know you have to kick the kid out of the house now at 24 but in our era we were on our own at 18. What is wrong with the new generation that can't grow up?

[onetrack]

Hasn't anyone noticed that the real reason for this mishap hasn't been brought up? The PIC was texting his wife, on final approach!! := :rolleyes:

It's interesting to note that one European pax reported in some detail that the aircraft went through "the heaviest rainstorm he had ever encountered in an aircraft, 2 to 3 minutes of solid rain", just prior to the ditching.

Anyone who has ever had any extensive experience with weather, knows full well - particularly in the tropics - that it is entirely possible to have clear sky and full sun, and little wind where you're located - yet only 2 or 3 miles away, you can have a violent thunderstorm raging, with strong wind gusts and heavy rain.

[philipat]

That would explain why the line itself issued a statement that the weather was good and not a factor in the accident.

I agree that tropical weather is a localised phenomenon BUT I have lived in Bali for 20 years and have a pretty good grasp of local weather conditions. On the day of the accident there was NO TS activity. That, of course, does not preclude localised rain showers on approach.

The boxes were an easy recovery job so the answers should be available shortly.

PS. I heard from my equally unreliable sources the PIC was actually sexting his girlfriend ;-)

[onetrack]

@philipat - I have no doubt you're firm in your conviction that there was no TS activity of consequence in the aircrafts flight path. I'm not so sure about the truth of the Lionair statement.

As we all know, the flight recording instruments will soon reveal all. I'm hazarding a WAG, that as it's fairly accurately recorded, that around 90% of aircraft crashes are pilot error - and that this was a totally brand-new aircraft - I'll wager the cockpit communications will be very revealing.

[ManaAdaSystem]

It can't be that difficult to find out if the weather was bad or not. There were a lot of surfers nearby who saw the accident, and headed straight to the crash site after the flight ditched.
And if there is a wall of water between me and the airport, I don't think I would see very much of it. Where they were flying blind below minima on a non precision approach?
Whatever happened to predictive and reactive windshear warnings? The bells should have gone off one way or another?

[onetrack]

There are many conflicting reports of just exactly what the weather and visibility was like, at the time, or just before the crash. The chief of the Ngurah Rai Airport's weather station is on record as stating that visibility was 6 miles and there was "no rain".
He might have been stating that he could see no rain. Other reports state that there were some TS clouds at 1700 feet, and a lot of low cloud beyond the 6 miles visibility range.

One has to ask, at a tourist location, in mid-afternoon, with large numbers of people about in public, why no-one actually sighted the jet going down - or even hitting the water?

The surfer who was in the water at the time of the crash, and who paddled out to rescue pax - has stated he never saw the aircraft go down - but he heard a huge splash, and he encountered a sudden large wave - which was the wave generated by the ditching.

This surely has to indicate that the aircraft ditched in low cloud - thus the lack of sightings of the aircraft ditching, by people on the ground?

Leaving out the obvious journalistic BS and the pax's errors in their statements, we have left, only the European pax's statement about heavy rain, and the PIC's statement that he intended to do a GA, but lost altitude so rapidly he was unable to carry out his intended action.

Exclusive: Lion Air crash pilot felt jet "dragged" from sky (http://news.yahoo.com/exclusive-lion-air-crash-pilot-felt-jet-dragged-063713747--finance.html)

'Extraordinary phenomenon hit Lion Air jet' | News.com.au (http://www.news.com.au/travel/news/extraordinary-phenomenon-hit-lion-air-jet/story-e6frfq80-1226621310661)

[dewajuice]

Lion's Air First Officer's rostering system ( verified by independent sources):

6 days on, 24 consecutive hours off duty per week. day by day schedule, permanent Standby. mandatory to fly more than 90 hrs per month otherwise you will be penalize. new system casino schedulle, pilots must pay to get a requested route and the requested crew. normally for locals.

There's MORE: Regarding pay:


FO top After line training: 2000 usd+8.5 use per hourr hour (100-120) hrs per month). Figures are before tax 11/Nov/11

Those hours ARE ABOVE INDONESIAN CASR (110 hrs).

From internal sources:

Agents take a significant cut for the foreigners. Part of the cut goes to Lion Air management for "kickback commission". Some are "shared" with pertinent regulatory authorities to "accept an arrangement"

Some flight hours are deliberately undocumented for cover ups. Additional pay provided at higher rates above legal flight hour limits. An audit was reported to have noted a pilot flew 160 hours in 1 month.

Management thinks those who do this are the "loyal" ones and get "preferential" treatment. When they get into an accident and found to hv violated, they r the " black sheep" if revealed.

[dewajuice]

From Now Lion Air wants to make money out of jobless pilots from India [Archive] - PPRuNe Forums (http://www.pprune.org/archive/index.php/t-444595.html)

"What is the penalty of early termination of contract?
Any termination at the initiative or caused by the behavior of the pilot will lead to a penalty of 100,000 USD"

Imagine a low time pilot who has invested tens of thousands of dollars in getting a CPL, unable to find a job, threatened for "termination" for "behavior", and asked to pay USD 100,000 as per a signed contract.

All they have to do is "pass the impression" that a "go-around" will b questioned and may be considered as "unacceptable behavior"

Obviously, this is nothing short of modern slavery!

Everything gets skewed with corruption and poor law enforcement.

[philipat]

With respect, and just to be clear, I am NOT saying that there was not any rain on the approach, just that there was no TS activity in the vicinity. I very often land in Bali on the default 09 Runway through scattered showers on and off through the approach, sometimes quite heavy, followed by complete calm and very good visibility.

There was localised light rain (Heavy if you are flying right into it) and scattered low cloud all across South Bali at the time of the accident. But no TS activity. Even Australian surfers know that if there is TS activity around, it's best to get out. They learn this in school.

Although Indonesian Corporations often work in mysterious ways, from the point of view of potential liability, I would have thought that their Legal Department would NOT have allowed Lion to issue a statement to the effect that weather was not an issue unless they believed that this was demonstrably the case.

Anyway, as you rightly note, the answers should soon be available. Like you, I expect that the CVR will be very interesting.

[smiling monkey]

This surely has to indicate that the aircraft ditched in low cloud - thus the lack of sightings of the aircraft ditching, by people on the

I've been flying in and out of DPS for the last three years and have a good appeciation of the weather conditions there at this time of year. Considering the METAR gives the temperature as 30 C and dewpoint 25 C, it's very unlikely that there's low cloud at the time. Reduced vis due to a torrential down pour is more likely the reason than being obscured by low cloud.

[TWT]

Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea (http://avherald.com/h?article=460aeabb&opt=0)

Flight was scheduled straight back to Bandung,not an international destination

[noughtsnones]

'Twill be interesting to see if engine inlet or EGT calibration (relative to original engine water ingestion test) or DFDR/QAR data mining can establish an abnormal severity of cloud burst.
0 n 1

[seckin]

I dont really like to speculate before the facts but as surfer close to the site reports he saw the plane with the splash sound, it makes me wonder why he didnt hear the sound of engines spooling up if a GA or stall recovery initiated, those things are very noisy over the open sea and if Full throttle was applied surfer would be aware of the plane earlier than the splash sound. He would state something like, i heard the plane and then it splashed into water etc..
Its just what came into my mind when i read his story..

[cwatters]

From an earlier post..

French businessman Jean Grandy, 49, one of four foreigners on the plane, said that the flight from the city of Bandung in West Java had appeared to be landing smoothly.

"The final approach was fine," he told AFP.

"Then suddenly, a cloud enveloped us. Torrents of water were pouring on us, it was an enormous downpour. It only lasted two, three minutes.

"It was almost as if it was night, even though the sun had been shining just before," said Grandy.

Two or three mins and dark? Sounds like a pretty large lump in the sky. Photos suggest visibility was otherwise quite good. Wonder why they didn't see it ahead of them?

[camel]

So it seems the go around was not executed as expected, due to:

Pilot ('s) error/CRM?
Technical problem with the aircraft?
Weather?

Or a combination..we can assume the CVR and FDR should give us the answer fairly soon.

[framer]

What does an accident look like on paper?
We have put forward a lot of ideas and suggestions about what may have happened at the pointy end, ie what the crew may or may not have done, doing that is an " old school" way of thinking about accidents IMO.
There may well be one, two or three errors regarding decision making, procedure, technical tasks etc from the pointy end, but I'd bet a months wages that there will be many more causal factors further up the chain.
How many decisions/policies of the Indonesian regulating body will have a hand in this?
How many decisions/policies of the Lion Air management team ( think recruitment, training, rostering SOP's) will have a hand in this?
If the aim is to reduce further accidents from occurring then these higher level causes seem to me, to be the most effective place to attack the problem. To attack the problem these links in the chain at least have to be acknowledged
as existing. As professional pilots we should be singing it from the roof tops rather than focussing solely on the last two or three links like Jo public naturally does.
Framer

[fireflybob]

Framer well said! Safety starts at Board Level / Swiss Cheese model!

Human beings do the best they can with resources they have available at time given their own training and background etc

These type of accidents are the result of a dysfunctional system

[Pucka]

framer..old school is out..it's the pigs running the farm now..bottom line is that it's more realistic to accept the prescribed hull losses than train the crew appropriately..new a/c products are supremely reliable so it's down to the most basic SOP's and no or little experience... Sad, I know. The irony now, is that the GA world requires the guys with good hands and feet..you can't fly an Otter through the QRH!!!

[ATC Watcher]

Very correct and very well said Framer .
How many decisions/policies of the Indonesian regulating body will have a hand in this?
How many decisions/policies of the Lion Air management team ( think recruitment, training, rostering SOP's) will have a hand in this?

Looking at the recent final report on the Sukhoi accident , the list of recommendations is surprisingly very long and detailed and for everyone., so there are ( and I know some of them ) individuals in Indonesia that want the old mammoth moved into the XXI st century..
This accident might in the end be a blessing in disguise for them.

[NEWYEAR]

As a reminder...Lion Air is considered an unsafe airline. That´s why they are not allowed to fly in USA and Europe. They have had many accidents and incidents. It´s an airline where pay to fly is the method to get a job.

[Old King Coal]

For those suggesting that maybe it was a mis-set Altimeter that might have caused this crash, the normal sequence and settings would be as follows:


Takeoff: Departure airfield QNH.
Climbing and passing the Transition Altitude and / or cleared to a FlightLevel: 1013 (STD).
Cruise (above transition altitude): 1013 (STD).
Descending and passing the Transition Level / and or cleared to an Altitude: Arrival Airfield QNH.

On the B737-NG the FMC comes pre-programmed with a default Transition Altitude (climbing) and a default Transition Level (descending), with the respective actual altitude / level typically being airline / airfield specific.

On each pilot's EFIS Control Panel there is a multi-function button which allows that pilot to select either QNH or 1013 (STD) on their respective altimeter.

If a pilot fails to select 1013 (STD) when climbing above Transition Altitude OR fails to select QNH when descending below the Transition Level, then the pressure reference field (at the bottom of the altimeter tape on their Primary Flight Display / PFD) will present as an amber box, i.e. to highlight that their particular altimeter is not operating in accordance with an appropriate pressure reference (as defined within the FMC).

Furthermore, were the pilots to have different QNH's set on their respective altimeters, such that the altimeters differed by more than 200 feet (for more than 5 seconds) then they would get a 'ALT DISAGREE' amber alert on their altimeters.

Also, the setting of the Altimeter (to QNH) is part of Boeing's 'Approach Checklist'.

Accordingly, in a B737-NG, if ones fails to set ones Altimeter to QNH (during descent & approach) there are at least two chances for a crew member to catch this omission, i.e. firstly via the visual 'boxed' amber cue on their altimeter, and secondly via the Approach Checklist.

And lets not forget that the Radio Altimeter would be making aural callouts at various altitudes (airline specific) and that these should normally be cross-referenced to the Altimeter(s) to confirm a level agreement (aka. 'airmanship').

The above not withstanding, there is nothing to prohibit the pilots from both having set an identical but incorrect QNH, in which case the above would all function correctly (aside from the Radio Altimeter being in error) in terms of procedure & matched settings, albeit that the aircraft would not in fact be at the correct altitude.

Nb. this would be a fairly major f**k-up for both pilots to make, but certainly not unheard of.

Given that the approach being flown was, by all accounts, a VOR, there are a number of way that this can be flown in a B737-NG, typically either via the autopilot and / or with reference to the Flight Director(s):

1) Fly it by use of VOR/LOC and Vertical Speed (with reference to distance versus height, from off of the relevant approach chart), with either the MDA set (or the closest 100' above) on the MCP, therein prohibiting the aircraft (if being flown via the autopilot / flight-directors) from descending below MDA (but which risks the aircraft levelling off, which might not be ideal); OR activating vertical speed mode but setting the Missed Approach Altitude on the MCP, which then allows the aircraft to maintain a Continuous Descent Approach down to, through, and below the MDA… with all the risks that that entails.

2) Select the relevant VOR approach in the FMC and then fly it via LNAV / VNAV, which assumes that all the correct buttons & options are pressed in the FMC and on the MCP. The typical failures here are the pilots forgetting to set a lower altitude on the MCP to allow the aircraft to descend (and / or then failing to reset the MCP altitude window for a missed approach) or, more insidiously, during the descent towards the runway, the aircraft switches mode from 'VNAV PATH' to 'VNAV SPD' (as annunciated on the FMA), which - in VNAV SPD - effectively means the aircraft is descending without following the prescribed vertical path: Such a mode change requires careful monitoring of the FMA by the pilots, and probable action to get the aircraft back on to the VNAV path.

3) Select the relevant VOR approach in the FMC and then press the APP button on the MCP and fly the VOR approach via the IAN mode, this being a mode which presents flight guidance in a manner akin to an ILS, albeit that this is still a VOR approach.

4) Fly the approach entirely 'manually' with reference to raw-data and distance versus height (from off of the relevant approach chart).

Now unless the VOR involves step down altitudes, or very cold weather, or a very steep approach angle, by far the easiest method of flying a VOR (in a B737-NG) is via the IAN option (see 3 above) !

Along with this, its likely(?) that this B737-NG was also fitted with something known as the 'Vertical Situation Display' (VSD) which presents a profile view to the pilots (on their Navigation Display / ND) of the decent phase down to the runway, including symbology to show the aircraft position wrt the planned descent profile and also its projected descent path.

So, in order to fly a perfectly serviceable B737-NG into ground / ocean, when following a VOR approach, one would either had to have suffered or instigated a number of systematic and / or SOP failures and / or major loss of situational awareness. Failing those, it must be an atmospheric anomaly (such as windshear), though one wonders why the wind-shear alerting function (also fitted in the B737-NG) did not activate, and for which the only course of action is an immediately flown go-around using all available power (and aggressively applied)!

[camel]

OKC

thanks for the very clear information.perhaps you could also add:

How low can you go on Autopilot on a non precision approach?

If you should disconnect the A/P at very low level, but leave the autothrust engaged , what would happen if you pitch up to go around and push the power levers forward,but dont press the TOGA buttons?

[repariit]

I have not read where the boxes were taken for readout. Anyone know where it is being done?

[Old King Coal]

Camel asked the following questions:

Q) How low can you go on Autopilot on a non precision approach?
A) It very much depends on which of those first three modes (which I described above) that you have selected, e.g. :

Mode 1) If aircraft is descended via vertical speed mode and the MCP altitude window is set to MDA (usually rounded to closest 100 ft above), the autopilot will level off at that altitude defined on the MCP: OR, if the aircraft is descended via vertical speed mode and the MCP altitude window is set to the Missed Approach Altitude, the autopilot will descend the aircraft until it impacts the ground (or ocean).

Mode 2) If the aircraft is descended via VNAV PATH the autopilot will stop the descent at whichever level is defined as the lowest level in the legs page of the FMC for the selected approach.

Mode 3) If the aircraft is descended via IAN, the autopilot will follow the vertical profile exactly as if the approach was an ILS (down to about 50' ?), and / or I suspect there will come a point when it might drop back into Control Wheel Steering (CWS).. though I've never investigated just what are the limits on this (company procedures prohibit it... though perhaps it's one to try in the sim?!)

Q) If you should disconnect the A/P at very low level, but leave the autothrust engaged , what would happen if you pitch up to go around and push the power levers forward,but dont press the TOGA buttons?
A) You will probably have a speed set in the MCP speed window, i.e. a speed appropriate to the flap setting. With the auto thrust engaged (regardless of whether you descending, or flying level, or climbing) the auto thrust system will do its best to maintain that MCP speed. Indeed you wouldn't actually need to push the power levers forward yourself, as the AutoThrust system will do this for you, i.e. to maintain the MCP speed.

Nb. In the scenario you describe, the aircraft / FMA will still think it's in the selected approach mode (because you haven't told it otherwise, e.g. by pressing the 'go-around' button, or re-selecting another mode on the MCP) and as such the flight directors will command a nose down pitch, i.e. to try an get you to follow the vertical profile of the descent (from which you are now rapidly diverging in a climb).

I should add (hence the edit) the due to the potentially bogus guidance that the Flight Director system can give you, i.e. when descending below the MDA on a non-precision approach, it is customary (and good practice) on the B737 - once you are visual with the runway (and certainly if continuing below the MDA) - to turn both Flight Directors briefly off and then on again. The causes the Flight Directors to disappear out of view for the remainder of the approach to the runway (i.e. you continue the landing entirely 'visually'), however, should you press the TOGA button, the Flight Directors will then reappear to provide go-around guidance. This is typically known as 'Flight Director Pop-Up Mode'

[roulishollandais]

@F14 #57 p.3

Anybody answered? :rolleyes:
UT 07:10Z
Local Time Denpasar, Bali 15:10
True solar time 14:50:12
Height of the sun 43°58'
Heading to sun 248°01'
Clock position of the sun for pilots (RWY 09) 5:15:O

[camel]

OKC

Thanks again for the explanation,seems like one could get into 'finger trouble' quite quickly if things are getting a bit busy ,with a change over in control at a critical phase of flight.

[Clear_Prop]

Just a couple of observations about Accuracy:

1. Surfers one of the most accurate meteorological measuring tools in existance. If its raining, they're in the pub, not the sea.

2. Radars are less accurate than you think. Reports of "100 ft below the approach path" are pretty meaningless.

Dont feed the animals. ;)

[Old King Coal]

mata abad: Sorry mate but I'm fully engaged at FlyDubai and I'm not sure that Lion Air could afford me... but, there again and much as per the old adage, "If you think safety is expensive, try having and accident!" ;)

[JPJP]

I should add (hence the edit) the due to the potentially bogus guidance that the Flight Director system can give you, i.e. when descending below the MDA on a non-precision approach, it is customary (and good practice) on the B737 - once you are visual with the runway (and certainly if continuing below the MDA) - to turn both Flight Directors briefly off and then on again. The causes the Flight Directors to disappear out of view for the remainder of the approach to the runway (i.e. you continue the landing entirely 'visually'), however, should you press the TOGA button, the Flight Directors will then reappear to provide go-around guidance. This is typically known as 'Flight Director Pop-Up Mode'

OKC,

I found this part of your post fascinating. I've spent the last eight years in the left seat of the NG and have never heard of this procedure. Its not in our procedures.

On an IAN approach the FDs will guide you down to 50 feet above the runway. However, it's not good practice to rely on them since you are below MDA. PAPI, VASI or visual reference are the approved guidance below MDA. Our book does allow us to "observe" the FD guidance below MDA in conjunction with visual references. It will provide accurate guidance with one caveat; a difference in actual airfield QNH/Temp and VNAV Baro, may cause a difference between VGSI and the GP indication.

Interesting stuff. Excuse the thread drift.

[despegue]

Has been SOP in all companies I worked for indeed. reset FD at DA or when going manual raw data.

[babemagnet]

Inside info tells me :

Go around due to heavy rain runway not inside.

Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.

[JPJP]

Despegue,

Interesting. Would you also turn them off below minimums on an ILS when visual ?

[JPJP]

Inside info tells me :

Go around due to heavy rain runway not inside.

Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.

One of the reasons that Boeing recommends that AT SPEED Mode be used instead of turning the AT off.

[Old King Coal]

JPJP: you correctly assess the issue, but you somewhat fail to highlight the risk wherein (if you'll please excuse me saying so?!) just because an IAN derived approach 'looks' like an ILS, one need always remember that is is not an ILS signal derived from and / or emanating from a position that is know & fixed along the runway, i.e. an IAN approach is derived from multiple inputs that are 'integrated' within your aircraft's FMC to generate approach guidance that seemingly reflects what one would see were one following an ILS (but it is NOT an ILS)... and if ever proof of that were needed, try flying an IAN approach when it is either very cold (i.e. well below ISA, indeed Boeing themselves tell you not to do IAN when it's v.cold) or conversely when it is very hot (i.e. well above ISA, when you'll likely break out at minimums with 3, or maybe even 4, 'whites').... and even v.10.8.A of the FMC does not (empirically) deal with significant ISA temperature errors in this respect (of IAN specifically; though one can somewhat modify this issue wrt to VNAV derived approaches).

The point of flying a non-precision approach (VOR) via IAN is to make the process as consistent & simple as possible (much as per the ILS procedure) but always with the caveat that one can follow the IAN guidance only down as far as the MDA (i.e. the last point by which one must 'visually' acquire the runway) and after that point (i.e. below the MDA) one must fly 'visually' to the runway and should not rely upon the IAN's Flight Director guidance (no matter how good a job it might seem to be doing... always remembering that IAN is not an ILS).

The point about turning off (then back on) of the Flight Directors, when following vertical guidance that is non-precision, is that that the vertical guidance is precisely that, i.e. NON-precision, being that it is generated onboard your aircraft and therein is subject to all manner of errors, whereas an ILS signal which is projected from the ground is subject to very few errors (in the most instances).

[Mareklug]

Simon Hradecky just added this passage, highlighted today in yellow, to his Aviation Herald entry:

"A witness on the ground observing the arrival of the aircraft from the terminal building of Denpasar Airport said, that he could see the aircraft descend towards the aerodrome at a normal rate of descent, but only realised something had gone wrong with the approach when the aircraft hit the waters instead of touching down on the runway. There was no rain or other obstruction of visibility around." Accident: Lionair B738 at Denpasar on Apr 13th 2013, landed short of runway and came to stop in sea (http://avherald.com/h?article=460aeabb&opt=4096)

This does not jibe at all with the crew coping with torrential rain and no visibility.

[lomapaseo]

This does not jibe at all with the crew coping with torrential rain and no visibility.

Most of the published crew comments could have been just as they hit the water, not before.

[flyingchanges]

It was raining so hard, it appeared as if we were under water...

BTW, we use VS to complete VNAV approaches that do not have guidance to the runway.

[JPJP]

OKC,

I completely agree with all of your post. No offence taken. Its an interesting discussion.

Our pilots understand the limitations of IAN, in fact we were one of the first carriers to buy it and use it. Understanding its limitations allows us to use it as another reference point on an approach. Our book is very clear as to its place in the hierarchy of references for the visual part of a IAP. It is remarkably accurate, simple to use and also not an ILS, as you said. We have a different philosophy on their use.

The use of FDs and AT are sometimes idiosyncratic to companies. Understanding their role should not be. The use of the AT may in fact be especially relevant to this accident.

Cheers,

[Old King Coal]

JPJP: As I'm sure you are well aware (though for the enlightenment of others) here's what the Boeing Flight Crew Training Manual (FCTM) has to say about use of the AutoThrottle on the B737-800:

"Autothrottle Use: Autothrottle use is recommended during takeoff and climb in either automatic or manual flight. During all other phases of flight, autothrottle use is recommended only when the autopilot is engaged in CMD."

"Autothrottle ARM Mode: The autothrottle ARM mode is normally not recommended because its function can be confusing. The primary feature the autothrottle ARM mode provides is minimum speed protection in the event the airplane slows to minimum maneuver speed. Other features normally associated with the autothrottle, such as gust protection, are not provided."

"Category II Operations: The autothrottles should be disconnected when the autopilot is disengaged."

"Decision Altitude (DA(H)) or Minimum Descent Altitude (MDA(H)): Disconnect the autothrottle when disengaging the autopilot."

"Final Approach using V/S: Disconnect the autothrottle when disengaging the autopilot.

Furthermore, the Boeing FCTM also includes numerous references to the following statement: "Turn both F/Ds OFF, then place both F/Ds ON. This eliminates unwanted commands for both pilots and allows F/D guidance in the event of a go-around." E.g. see: Circling Approach OR Final Approach using V/S....

Accordingly, unless one is flying an Autoland (i.e. landing with both autopilots engaged), when you disconnect the autopilot, Boeing recommend that you should also disconnect the auto-throttle.... and for certain non-precison approach types (if and / or when below the MDA on those approaches) also turn off, then on, your Flight Directors and wherein as JPJP (correctly) states above: "On an IAN approach the FDs will guide you down to 50 feet above the runway. However, it's not good practice to rely on them since you are below MDA. PAPI, VASI or visual reference are the approved guidance below MDA;.... a difference in actual airfield QNH/Temp and VNAV Baro, may cause a difference between VGSI and the GP indication."the point being that you can't rely on it to be correct, hence why it's classified as 'non-precision' (unlike an ILS), and that therein the Flight Director guidance might be duff... so turn them off to avoid any ambiguity in the guidance one is following (but have them available - in Pop-up' mode / hidden out of view unless the TOGA button is pressed - in the event that one has to go-around) !

Boeing have / had also issued a Operational Bulletin / Amendment to Part B FCOM 1 (which presently and for the life of me I can't seem to locate... though I'll edit this post with the relevant link when I do find it) which explicitly prohibits the practice of using "Speed Off" / 'Arm' mode during an approach & landing (apparently due to the auto-throttle - when in 'Arm' mode - being able to cause a tail-strike during a go-around from a very low height, as it can seemingly apply TOGA power 'too aggressively', and that there's also the risk that the auto-throttle might choose that very moment to fail and therein not apply the TOGA power that one is expecting, whilst one errantly uses both hands to pitch the aircraft into a climb... go figure?! :rolleyes:.. ).

[FlightPathOBN]

I am curious on the mechanics of the weather radar and wind shear alert system. Doesnt the windshear alert use the weather radar? I am aware that some models use a laser system for windshear, I am just not positive about the connection between the 2 systems.
If the settings for the weather radar had been to look up, with the windshear system auto engage at 2500 feet, does this automatically reposition the dish?

[PJ2]

Inside info tells me :
Go around due to heavy rain runway not inside.

Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added.(I take 'inside' to mean "in sight").

If true, that sounds more and more like One-Two-Go at Phuket and brings in the notion that the aircraft may have stalled, ("rain-roughened" airfoil?) - I see BOAC's thread on TechLog - good one :ok:

The remarks make the most sense of anything produced on the thread thus far, (in terms of actual/possible causes. I certainly agree with most observations regarding the corporate and safety culture at Lion Air).

The METARs do indicate local CBs but not TS. That there was heavy rain there is little doubt but I find the windshear theory puzzling as it takes more than the kind of downdraft just heavy rain brings to compromise the energy level and reserve thrust from what would be a fairly light B738, (guessing 55t or so).

I wouldn't be surprised if the pitch attitude was quite high at impact, (15 - 18deg or so).

PJ2

[noughtsnones]

Earlier, my speculation was to point out the possibility that there may be a way to at least qualify, and hopefully quantify, the rain observations (and occasional absence of same) from the published reports and witness statements.
The statements and reference documents here and on the "Aerofoils in heavy rain" thread suggest the possibility of other cheese holes, at least one of which needs to be robustly filled: -
- The temperature and pressure sensor performance, affecting data accuracy; leading to one or more of
- Aircraft flight control (margins) becoming degraded
- Engine control may become degraded – margin reductions in auto-relight, idle setting, acceleration schedule(s) and handling bleed (water centrifuging)

0 n 1

[JPJP]

OKC,

We don't use the Boeing FCOM. Boeing approves our manuals along with the FAA. You'll probably be horrified to know that we use the AT without the AP, and we also de - select the AT on occasion. We do turn off the FD during circling approaches for obvious reasons, then we turn them back on prior to selecting a lateral and vertical mode. We only circle with VMC (common here). As I said, Boeing approved our manuals.

I disagree with you on the use of the FD below minimums, specifically in IAN, it's a useful tool. One of many, as long as one isn't relying on it solely and understands its limitations. I also multiply DME times three :8

We rely on our pilots not to forget to push the Thrust levers forward during a go around and not to allow a TOGA tail strike. So far so good ...... Touch wood.

By the way; low speed protection is disabled below 27feet. The incidents with AT de-selected, during the flare, were caused by low speed prior to 27 feet.

Apologies for derailing the thread slightly. Although; if this was a botched Go-around, the AT being on might have saved the crew from the walk of shame. As would shoving the thrust levers forward ;)

[Machinbird]

I wouldn't be surprised if the pitch attitude was quite high at impact, (15 - 18deg or so).
Yep.
That is probably how the back of the aircraft got broken, maybe the starboard HS too (with the aid of a bit of coral)

[ExSp33db1rd]

All the technical jargon between JPJP and OKC makes me want to go and lie down - trying to get all that right and coping with all the variable options whilst approaching minima ? Just proves that today's airline pilots are computer button pushers, not pilots.

I always found it much harder to accurately set up, and control, even the basic autoland facilities of the auto-pilots of yesteryear to accomplish a Cat III ILS - than just clicking the A/P and A/T out and just flying the bl**dy thing, which of course was forbidden, it has to be auto all the way to touchdown - but on a Non-precision approach such as this was ??

When in doubt look out of the window and fly the aeroplane.

We rely on our pilots not to forget to push the Thrust levers forward during a go around.......

What an indictment of modern airline procedures !

How many more LIONS will be led to the slaughter ?

[JPJP]

ExSpeedbird,

Apologies for the discussion between OKC and myself. I respect his opinion and its an interesting subject. His airline adheres to the Boeing manual. My airline had our manuals approved by Boeing. Nevertheless, there's a difference in procedures.

You're right. It's become an even more complex business. You also summed up the essence of the solution - Fly the airplane.

Today's worst professional pilots are button pushers. The best are able to operate the aircraft from zero level of automation through to the highest. Equally important is knowing when, and how much automation is appropriate.

Interestingly: I find that new F.O.s, when cleared by ATC for a tight visual approach, feel automation pressure. They then revert to manual operation of the controls. This is reassuring in some ways. It indicates to me that they are more comfortable hand flying the aircraft. It also shows that in some circumstances the automation can become slightly overwhelming. Either due to circumstances or inexperience. These are pilots with many thousands of hours in Jets, but the specific type may be new to them.

Lion Air appears to have some very, very new pilots.

[bubbers44]

Lomapaseo, I agree with your statement because I posted what a resident said about two miles away that the weather was fine. The wall of water may have been post crash. The FDR will say where their thrust levers and attitude were at and airspeed but I have a good guess. Automation dependency had them pushing buttons when they should have been aviating with their hands like us old timers always did. Who cares what the buttons do just aviate. That is what we were trained for.

[ExSp33db1rd]

As a teenager - 60 years ago (!) - I remember my then girl friends RAF Wellington Bomber pilot Father telling me, as I joined the RAF myself - " When in doubt, lash out, everything forward for speed " Mixture,Pitch,Throttles, Carb. heat," etc etc (according to type ).

Can't see what's different about that theory today ?

[KBPsen]

I posted what a resident said about two miles away that the weather was fine.He actually said he lived 4 miles east of the 27 threshold, which would put him in the water. He then said he lived in Sanur which is actually northeast of the airport and further away than 4 miles. Add the 2 miles to rwy 09 and we are already well past 6 miles away. He then said he had lived there for 30 years only to say a bit later that he had lived there for 20 years.

He wouldnt be high on my list of reliable sources.

[philipat]

@OKC. Thank you taking the time and trouble to explain the NG systems and JPJP for adding to an excellent discussion.

@PJ2. Based on my observations of the weather in Bali at the time of the accident, I have always thought that your conjecture may be correct.

Just to add, this flight came from Bandung so was landing from the West onto 09. This configuration generally avoids the stack over South Bali with separation maintained by speed and usually involves a very slow and gentle descent from just after Surabaya. So there should not have been any last minute panic.

As an inadequate analogy, the NG system reminds me somewhat of the iDrive system in my BMW. It's a miracle of modern technology which I never use once set. Too many options and too difficult to use. Would it not make sense for line SOP's to minimise the number of options used, especially for Landing then incorporate that into Landing checklists?

[arba]

Originally Posted by babemagnet
Inside info tells me :
Go around due to heavy rain runway not inside.

Badly flown go around due to the fact the autothrottle was off. Only toga was pressed and no thrust was added

Insider info :

F/O selects FLAPS 15 passing the MDA, without go-around command (that's explain the "drag down from the air" claimed by PIC).

[tommy1-8706]

Old King Coal, thanks for your contribution, especially the explanation of Integrated Approach Navigation.

The Bali VOR/DME approach for 09 (15 MAR 13) has a profile requiring 290ft per nm. (2.74 deg rather than 2.8 as quoted) This results in an arrival at the 2.0DME Missed Approach point at 500ft, still above the MDA of 470ft.


Could this upset the automatics (or a crew) when performing an IAN approach ?

[tmny]

@philipat

Sanur is about 10 miles away from the point of the raining or not raining.

Witnesses were inside the plane, pax, 2 pilots and reported rain.

Rain is local and makes it difficult to forecast it, not only in Bali. U can also see a dark clound in the pictures made shortly after the crash.

It would be surprising, that only rain or maybe the more difficult handling of a B737 than a bmw cause the crash.:ok:

[bubbers44]

I live in the Florida Keys so know how localized cells are but wait until the FDR results are out and see what really happened. Thrust lever position, speed, sink rate and attitude and we will know what happened. I have flown into a cell at MIA and gone around with a FAA check airman looking over my shoulder and it was a manual normal go around. No big deal. But we were just flying a B727 so couldn't push any buttons. Life was simple then.

[bubbers44]

This all happened below MDA when we lost the runway.

[philipat]

I don't know how many times I have to repeat this but I DID NOT say there was no RAIN. I acknowledged from the outset that "There was scattered low cloud and some localised rain showers" BUT NO TS. And I stand by that and only that. That is a fairly normal condition landing at DPS yet this is the first time that any aircraft has landed on the reef.

The presence of surfers, as noted by other posters also, would tend to confirm the lack of TS, when all good surfers retire to the bar.

I find it most interesting that Lion would have issued a statement to the effect that there was no rain and that visibility was good when they could have retained that possibility as a mitigating circumstance. If proven incorrect, as does seem to be the case, Counsel for the Passengers will latch right onto that.

[80-87]

It appears the aircraft was in rain...have a look at the windshield wiper positions from the photographs. They were in use.

[Old King Coal]

ExSp33db1rd: Wrt "When in doubt look out of the window and fly the aeroplane."

Always & indeed!

Automation, when used correctly & appropriately, and when one understands it (though more especially when one understands its limitations) can be excellent at helping get the aircraft safely & smoothly down to a position where the remainder of the approach can be conducted 'visually' (i.e. without further reference to instruments,... aside from keeping an occasional eye upon ones ASI ;) ).

I would add that, imho, the avionics in the B737 are actually quite slick, i.e. especially so when compared to, say, the B757/B767 (they being the only other Boeing types that I have flown), and certainly so in a B737-NG if it's been fitted with all the bells & whistles (ours even have a HUD/HGS). BUT, one still needs to keep on top of it and be able to recognise when the automation is going wrong... and then, it's click click (autopilot off) + click click (auto-throttle off).

And by way of examples, I'm sure we've all seen plenty of approaches wherein people get themselves 'high' as a result of failing to recognise that the VNAV PATH simply isn't working (regardless of what might programmed in the FMC)... and worse, get themselves 'low' when the aircraft silently drops out of VNAV PATH into VNAV SPD though, even on a VOR approach (in a B737NG, at least) you will then likely get a "GLIDESLOPE" aural alert (though for the life of me I can't see why Boeing didn't make that call-out say "GLIDEPATH", which would be a technically more accurate call-out based upon what one is following vertically).

Fwiw, amongst other places, we use the 'automatics' for non-precision approaches into Kathmandu (VOR R02) and also into Kabul (RNAV R29)... and both can give one a few uneasy moments and / or even royally f**k-you-up (especially due to 'operator' error!)... but it's how todays companies want it done!... the 'skill' is recognising (=experience) when it's going wrong and having a strategy & ability to deal with it (be that to either continue or to go-around)!

You might also consider that in todays litigious society and / or where the 'no-blame culture' is now very often highly punitive (it being a state of play which many companies impose, therein paying veritable 'lip service' to the true ethos of 'safety') which leads to pilots being somewhat opposed to actually 'flying the aeroplane' and therein becoming a slave to the automatics.

Fwiw, I (too) apologise to all for what might seem to be thread creep but, as a Captain on that type, I have a most definite interest in how / why this crash happened and, reading some of the previous posts, there seemed (to me) to be some 'confusion' out there about various aspects of the operation and abilities of the B737NG, both in terms of altimeter setting procedures and also wrt the modes (and limits therein) of how one might fly a non-precision approach, in this aircraft type.

For the benefit of all, this video presentation is legend: Children of Magenta - YouTube

[Capn Bloggs]

imho, the avionics in the B737 are actually quite slick
Have a go at an MD system (MD11/717). VNAV PATH?? VNAV SPD?? Pardon the French, but WTF?? :)

[Willie Everlearn]

"I would add that, imho, the avionics in the B737 are actually quite slick, i.e. especially so when compared to, say, the B757/B767"

Wow.
I'm typed on the 73NG, 75 and 76.
Either I've misunderstood your remarks or you must be one of very few pilots on the planet who think the NG avionics are quite slick. But there we go.

The inability to disengage APPR mode without introducing a lot of drama at a rather inappropriate time is a bit ridiculous AND dangerous IMHO. Perhaps Mr. Learmount might look into that during his research into botched go-arounds. He might find a smoking gun.
The obvious lack of EICAS in the NGs despite their being marketed much later than the 57 and 67 is a bit of a miss on Boeing's part I'd say. And it isn't about to change on the MAX either. Could the NG be better? Hell yes!! Is the MAX going to be better? Hell no!! New engines. That's it?
That's it.

But to diminish the B757/767 this way ...really???

Otherwise, I enjoyed your post.

[Old King Coal]

Capn Bloggs: I'd love to fly the MD11, and I nearly did, but it slipped through my aeroplane net... but never say never, eh?! ;)

VNAV PATH = basically the vertical profile that is computed, by the FMC (prior to Top of Descent), as being the most efficient descent path, i.e. when passing over a projected set of waypoints (as defined within the FMC Legs page), whilst also making allowance for any altitude constraints, and using a range of speeds (programmable within the FMC and / or 'cost-index' derived).

VNAV SPeedD = the vertical mode that the aircraft reverts to when it decides that it is unable (for any number of reasons) to follow the idealised VNAV PATH. With suitable pilot input it might be possible to recapture the original VNAV PATH, albeit that this might require more robust inputs, such as 'Speed Intervene', or 'Level Change', or 'Vertical Speed', or even manual flying by way of actually moving the thrust levers & flight controls oneself, forsooth ! :rolleyes:

Willie Everlearn: In the B757-200's & B767-300's that I flew it was not possible to fly a VOR coupled to an autopilot, i.e. one could couple the autopilot to the 'LOC' (and indeed at glideslope capture it would automatically engage all 3 autopilots, whether you wanted it to or not) but there was no facility for 'VOR/LOC', i.e. to make the autopilot capture and maintain VOR radial (unlike the B737) and thus use of the HDG knob was required in order to keep the VOR course bar in the centre.

The B737 Classic & NG does a nice job (inside the 'glass') of automatically (i.e. no pilot input required) making localiser sensing 'reverse sense' when one does a back-course localiser approach (or maybe when doing a circle-to-land from the front course of an ILS approach), though I'd equally contest that one can't couple a back-course localiser to the autopilot in a B737, though I seem to recall that in the B757/B767 one could do that (i.e. if you pressed the BCRS button on the MCP... it being a button which the B737 does not have?).

Furthermore, in the B757/B767 (that I flew) there was no GPS fitted and therein one was reliant upon the 3 IRS's and, good as they were, they are not even close when compared to position keeping available via the GPS fitted as standard in a B737NG... and which no doubt accounts for why the B757/B767 suffer somewhat wrt being able to comply with RNP required of most RNAV departures and arrivals ?!

As for exiting out of an approach mode being a 'drama'... all of the aforementioned aircraft types have their idiosyncrasies in this respect.

E.g. For getting out of an ILS APP mode on a B737, my preferred technique is to reach down and de-tune/re-tune the ILS frequency (it's just a simple button press) wherein, if the autopilot happens to be connected and flying the ILS for you, it will then revert in to Control Wheel Steering (CWS) and maintain which ever amount of pitch & roll it was doing when the tuning button was first pressed (and it will not re-engage in APP mode, i.e. when you press the tuning button a 2nd time, to re-tune / re-select the ILS. To capture back on to the ILS you'd need to re-select the APP button on the MCP).
One can than select any other mode (even APP) on the MCP and the autopilot will comply (as it's still engaged, albeit in CWS until you select another MCP mode), therein this is a natty method of breaking out of an ILS approach, e.g. perhaps into a circling manoeuvre (especially when one considers how it then subsequently manages the 'glass' / LOC guidance when one approaches the runway from the other end), and doing so with the autopilot always engaged.

To do the same thing on a B757/B767 (and it's been a few years since I last flew them), I seem to recall that if one was coupled up to an ILS with autopilots engaged, to break-out of the ILS, e.g. into a circle-to-land, all one had to do was press the Go-Around switch, then immediately press ALT HOLD, and then select a different pitch & roll mode on the MCP. We used to use this method when circling to land our B757's at Chambéry Airport (IATA: CMF / ICAO: LFLB) though one needed to remember to press the BCRS button on the MCP (when on the downwind leg), if one wished for correct LOC sensing as one approached the runway from the other end.

The point here, for either B737/B757/B767, being to use the most accurate method to get aircraft down to circling minima, then breaking off into Circling, all whilst keeping the autopilot engaged to 'reduce workload'. :D

Wrt to the Cat IIIB capabilities of the B757/B767, you might be interested to know that the B737 can now do that too... indeed we use our HGS/HUD for that very purpose, and therein whilst we are currently only Cat IIIA, we are rapidly heading towards approval for single-engine landings, in 75m RVR, manually flown!

I totally agree with you about the lack of EICAS in the B737 and, fwiw, the B757 remains my favourite aeroplane !

[PJ2]

Philipat;
PJ2. Based on my observations of the weather in Bali at the time of the accident, I have always thought that your conjecture may be correct.For one thing we know that the windshield wipers were likely operating just prior to impact.

In my experience, the windshield wipers are used very rarely. The slipstream blows most water from the windshield. It takes a lot of rain to obscure forward visibility and what's more, the wipers usually struggle keeping up.

My thought is, if the wipers were being used, (and they're not in the 'parked' position (http://www.pprune.org/rumours-news/512476-lionair-plane-down-bali-8.html#post7792156)), then, however briefly, (and I agree with the poster who said you can't forecast these things), the rain had to be heavy.

For those who don't fly these aircraft and may be curious about the go-around manoeuvre, with minor variations, standard go-around procedure is simultaneous setting of pitch (15deg minimum) & power, (TOGA: Take Off / Go Around thrust), while pushing the TOGA buttons to set the FDs and any other auto-items to the go-around mode, (or, in the Airbus, setting thrust levers in the TOGA detent), retracting the flaps (usually one step) and getting the gear up.

The PNF monitors pitch & power to make sure the aircraft is climbing and if pitch-power-thrust aren't what they should be, is required to call out the parameters, (speed, altitude, vertical speed, pitch). It's a busy time and demanding of cockpit procedures and crew discipline. The main problem in go-arounds is not getting the pitch right up to the required attitude. Another item is forgetting to raise the gear, (no one says, "positive rate", which is the cue). But in sims, on the line or in flight data, I've never seen anyone leave the power where it was for the approach - it's always 'in the kitchen'.

PJ2

[India Four Two]

I've been following this with interest and after travelling for a day, another three pages to digest!

OKC,
Thanks for your description of the 737 NG approach modes, particularly the IAN mode. You have answered a question I was going to ask before posting the following observation.

The 09 VOR plate posted early on in this thread shows a 2.38 degree descent path from from the FAF with crossing altitudes at various DME distances, including the MAPt. This is the first time I have seen an NPA plate with an approach slope. Out of curiosity, I checked the various altitudes with the 2.38 degree angle and they all agree. I then extrapolated the descent path and discovered that it reaches sea level exactly at the runway threshold. I find this surprising. I would have thought the TDZ would have been a better design criterion.

This seems to be a potential trap if a crew continued to use the IAN mode when continuing the approach after the MAPt.

[lederhosen]

As I suggested in post 362 not setting go-around thrust is at least a conceivable scenario. The good news is that no one was killed and with the plane easily accessible we should know relatively quickly what really happened.

The very good news is that if (so far we are all speculating) this really was operator error, then here is clear proof that pay to fly / erosion of conditions / call it what you will, is financially a questionable idea.

It is unlikely that the authorities are going to act as quickly as we would all like (at least those of us at the sharp end) to legislate worlwide against P2F. But if you write off brand new Boeings as a result then the insurance and leasing companies will start to take notice. So far management have told us everyone is doing it and there is no issue. Events are starting to suggest otherwise.

Insurance for eighteen year olds in high performance cars is logically hard to get. Once the insurance and leasing companies recognise pay to fly is very similar they will understand what a spectacularly bad idea it is financially and do something about it.

[PJ2]

This seems to be a potential trap if a crew continued to use the IAN mode when continuing the approach after the MAPt.
Well, it shouldn't be a trap for anyone who can fly a visual approach in a transport, and see/use the PAPI, which is set at 3deg. After all, a non-precision approach is essentially just a cloud-breaking procedure that keeps you vertically away and safe from obstacles until you can see the runway.

PJ2

[India Four Two]

PJ2,

I agree with you, but there is a lot of discussion these days about automation dependency and the Children of the Magenta. It just seemed odd to me that someone would design an approach where continuing below the MDA, using the same descent rate, would cause you to arrive at a concrete breakwater, rather than the TDZ.

[PJ2]

India Four Two - thanks for the reply. I was kind of thinking that that design may have more to do with how it is required to be constructed, as the expectation is you'd be visual to continue the approach and the descent procedure isn't intended as precision guidance. I see your point but by the time the design has done its job, you should be flying visually and where it "ends up" is not vital.

I certainly understand the remarks regarding, and the problems concerning automation dependency and have even written about it in the past. That "generation of children" is just starting out, (it's about fifteen years old now) and it's going to take some time and some accidents to take the industry back to actually teaching and knowing how to fly vice "managing" the airplane.

PJ2

[Weapons Grade]

Just a thought, although it could be moot if TOGA thrust was not applied in a GA.
Doesn't the Boeing FCTM "recommend" adding 50ft to all MDAs to allow for undershoot in the GA?
This would then make the MDA 520ft and not the charted 470ft, with the MCP set for the nearest '00 feet (should be 600ft but who knows until the DFDR/CVRs are analysed.

[tmny]

This picture shows at the upper right a dark raining cloud:

http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2013/4/15/1365997424663/People-around-the-Lion-Ai-008.jpg

Copyright and Photograph: AFP/Getty/Indonesian SAR
Link: Downdraft theory in Lion Air crash | World news | guardian.co.uk (http://www.guardian.co.uk/world/2013/apr/15/downdraft-suspected-lion-air-crash)

And the Guardian reported:

"According to the Flight Safety Foundation, bulletins for pilots at around that time indicated a few storm clouds at 518 metres (1,700ft) and a wind blowing moderately but varying in its direction from east-south-east to the west. "

WADD 130730Z 15006KT 110V270 9999 FEW017CB SCT017 30/25 Q1007 NOSIG
WADD 130700Z 09006KT 9999 BKN017 30/26 Q1007 NOSIG
WADD 130630Z 16003KT 090V190 9999 BKN017 30/25 Q1007 NOSIG

[Jonty]

The reason you add 50ft is due to the aircraft descending below MDA on the go around when conducting a CDA to minimums. So you wouldn't have the MDA+50ft set in the MCP, you would have the go around alt set.

[BOAC]

The 09 VOR plate posted early on in this thread shows a 2.38 degree - I do not draw the same conclusions. If you refer to post #244, I see a nominal 2.8 degrees to the VOR position which is not far off the TDZ? I cannot see any problem with the chart. As WG says, DA should (normally) be 520' for a charted MDA approach, but Lion may not have implemented that - some carriers apparently do not.

If we therefore assume that the charted approach would 'aim' at the VOR, and that we appear to be surmising loss of visual BELOW MDA, the actual slopes etc are not particularly relevant, and would have been 'aiming' roughly at the TDZ anyway. We must look elsewhere. If, and NB IF, we are looking at an 'approach power g/a', then no amount of chart wizardry would have helped.

I think we also need to drop this 'P2F' thing on this accident. I have seen either 10,000 or 15,000 hrs quoted for the Captain, and if those hrs are genuine and he was still 'paying' for his flying.......................? Also P2's (?2000?) hrs are less relevant even if he was P2F since it has been said that the Captain 'took over'.

[Sikpilot]

WHO will be examining the FDR and CVR and is there any chance of shenanigans if they don't like what comes up?

[Capn Bloggs]

The 09 VOR plate posted early on in this thread shows a 2.38 degree descent path from from the FAF with crossing altitudes at various DME distances, including the MAPt. This is the first time I have seen an NPA plate with an approach slope.
You need to hop onto your authority and get it to include the approach angle on the charts. We've had them here for years. Depending on your company's SOP approaching the MDA, it is essential because it tells you what FPA angle to set approaching the MDA/DDA. If the chart says 3.46°, no point in setting 3° if you really want to get in. Similarly in this case, if you set 3°, you'll end up low as the approach angle is 2.8°.

We have also had an Altitude/Distance table for every mile in from the FAF for many years. Good for SA or when the database approach is not available.

In practice, these database approaches take to us 50ft-ish AGL over the threshold and I would be surprised if this one did otherwise. So they "aim" at short final using the VOR for tracking reference, and the DME distance (adjusted for distance to the threshold) for slope reference.

[BPA]

Folks,

Both Transition Layer and myself in posts 255 and 260 on the 14th mentioned there was weather on final at the time of the accident and the Virgin Australia aircraft went around due to this weather.

Well today I was sent the following link to this website containing a photo of heavy shower on the final approach path, taken from the terminal at time of the accident.

WWW.CRASH-AERIEN.AERO ? Un avion de Lion Air tombe en mer à l'atterrissage à Bali (http://www.crash-aerien.aero/forum/un-avion-de-lion-air-tombe-en-mer-a-l-atterrissage-a-bali-t24509.html)

This photo (if true) matches the information about the Virgin Australia go-around due weather, the Lion Air passenger report about heavy rain just before they hit the water and the photos of the 737 showing the wipers not parked. I think this photo puts to bed people saying there was no weather on final at the time of the accident.

[toffeez]

"Who will be examining the FDR and CVR and is there any chance of shenanigans?"

Boeing will be one of the first to get a copy of the FDR data. Probably they already have it.

[A4]

Depending on your company's SOP approaching the MDA, it is essential because it tells you what FPA angle to set approaching the MDA/DDA. If the chart says 3.46°, no point in setting 3° if you really want to get in. Similarly in this case, if you set 3°, you'll end up low as the approach angle is 2.8°.

Er, please tell me you're not serious. How/where would you "set" FPA approaching MDA? At MDA you're either visual or you go-around. If you've flown the approach as a CDFA (Continuous Descent Final Approach) - as jets are - as opposed to "dive'n'drive" then you're already on the FPA you should be - there is nothing to "set". Leave the autos in to acquire the visual picture, disconnect and then FLY THE AIRCRAFT VISUALLY TO THE TOUCHDOWN POINT. Don't chase the PAPI's aim to touchdown abeam them on the runway.

The notion of fiddling with MCP/FCU selections when visual <400' AGL is foolish. If you've flown the approach correctly then at MDA/DA you're in exactly the correct spot, on "FPA", to complete the manoeuvre visually.

A4

[Desert Dawg]

The image that BPA refers to from the other forums. Doesn't look pretty..

http://www.flyrelax.com/images/JT904-6.jpg

[despegue]

That is absolutely not microburst weather. just a small tropical shower, totally normal anywhere in the Tropics. yea it reduces visibility, makes runways very wet and sometimes very slippery, but this is not severe windshear, aircraft dropping of the air while having full thrust kind of weather.

[philipat]

Absolutely agree as I keep trying to say. These conditions are very common for landings at DPS and this is the first time an aircraft has landed short. There was NO TS activity in the vicinity. NOT microburst/Windshear conditions at all. TOGA weather yes, if at MDA but NOT, as you put it "Dropping out of the sky at TOGA thrust weather" I think PJ2 might be onto something.

I'm not quite sure but it appears on some of the pictures that the slats are in landing configuration (I am not aware of any pictures that show the flaps configuration) and, according to earlier reports and pictures, the gear was torn off on the reef. How can that be ?

[KG86]

A4:


At MDA you're either visual or you go-around.


Not true. You can level off at MDA and run in towards the MAP, even if still IMC. You only have to make a decision at the MAP.

[fireflybob]

Not true. You can level off at MDA and run in towards the MAP, even if still IMC. You only have to make a decision at the MAP.

Depends on specific Company procedures and also whether or not you are circling. Many airlines now fly a Continuous Descent Approach on Non Precision, therefore (assuming not circling) if not visual at minima you Go Around.

[BPA]

Yes it is typical weather, but perhaps the crew got caught out by it at the minima or just after and they elected to go-around. However if the Autothrottle had been disengaged earlier in the approach, they hit TOGA for the go-around but failed to push the thrust levers up but followed the flight direct (go-around mode) the aircraft would have pitched up, speed would decrease and the aircraft would continue descending until it hit the water. So the WEATHER would be a contributing factor.

[philipat]

Or even stalled if still in landing configuration? See PJ2 hypothesis.

[astir 8]

Hi Guys

well I just survived one leg Merauke - Jayapura as SLF on Lionair then Jayapura - Makassar - Jakarta on Merpati which according to some posters seems to make me about as lucky as a Lancaster crew doing 3 trips to Berlin & back. However from where I was sitting the cabin staff all appeared entirely professional and the landings were no more "arrivals" than most of the other heavy jet flights I've ever had.


It might be worth a mention that many of the airport runways in Indonesia are perched on the edge of islands, with either high ground to one side or one end, and often with cloud/rain on the high ground and at times seriously heavy rain storms. It can't be easy for the guys up front sometimes.

Plus there are about 240 million Indonesians spread over a huge area and they travel a lot. Indonesia may possibly compare with a fair bit of the whole of Europe in terms of daily aircraft movements, but in more difficult operating circumstances.

So In my extremely humble and worthless opinion I think some of the comments on this thread may have been a teensy tad OTT.

I pass on the P2F issue. I've always had to pay for my flying

[Capn Bloggs]

Er, please tell me you're not serious. How/where would you "set" FPA approaching MDA?
Descent in VNAV. At DDA+300ft: set charted FPA, then set Missed Approach Altitude, then do whatever you have to do when you get to the DDA: as you say, go Visual or Go Around.

[smiling monkey]

So In my extremely humble and worthless opinion I think some of the comments on this thread may have been a teensy tad OTT.

Does that include your first paragraph? :rolleyes:

[smiling monkey]

The image that BPA refers to from the other forums. Doesn't look pretty..

http://www.flyrelax.com/images/JT904-6.jpg

My logbook reveals that I've landed at WADD 220 times, with 65% of the time on 09 which is the prevailing runway for most of the year, so I guess I'm qualified to say the cell and associated downpour that you see in that photo is definitely not inline with the final approach course for 09. The inbound course (091) if offset 5 degrees to the left of the runway centerline, and would be well out of view of the photo.

[Yankee Whisky]

May I suggest we wait for the FDR results before pontificating on the reason for this undershoot.
It was suggested that there is no effect from a "normal" rain shower, however, "normal" depends on the IAS and can be affected by tailwind due to vortex and/or rain on wings that are close to stall speed as when a pilot is trying to make a short field landing i.e. "dragging it in".
Therefore, let's wait for the facts before going into 20/20 vision speculations !
As a long term soaring pilot I am very aware of water on the wings and the negative affect it has on L/D and this I respect in the highest degree when flying near rain and CB's.

[philipat]

And I am also NOT convinced that is a picture taken on the day of the accident. Is there any proof of that? Granted, my position is some distance away and granted that these cells are localised. But that sure as hell doesn't seem to portray what I saw on the day. Even if it was, It's not microburst/windshear conditions. And as you correctly say, it is way of the approach path. Winds were light SE so would likely have interfered with approach LATER and FURTHER OUT.

[A4]

Descent in VNAV. At DDA+300ft: set charted FPA

Is this the standard method on the 738? Is it not permissible to allow VNAV + AP + A/THROTTLE to fly right down to Minima?

Without wishing to start an A v B debate it does seem a bit of a faff (English for nuisance). Selecting an FPA executing, confirming on FMA right at about the time you want to be looking out... FD's off then ON to ARM pop-up? TOGA buttons.....it all seems a bit high workload at a critical time. Does the AP have to be disconnected to execute the GA?

A4

[smiling monkey]

WHO will be examining the FDR and CVR and is there any chance of shenanigans if they don't like what comes up?

These guys will. Looks like they've just caught a prized catch out of the sea at Kuta beach....

detikNews : situs warta era digital (http://news.detik.com/readfoto/2013/04/16/104729/2221343/157/1/ini-dia-cvr-lion-air-yang-jatuh-di-balind771104fvt)

[lomapaseo]

kj;askmfg

http://us.images.detik.com/customthumb/2013/04/16/157/cvr1.jpg?w=600

[PEI_3721]

Although the details of this accident are far from clear, there are aspects which we can consider and learn from.

See the incident report below. There are many good safety lessons re wind-shear, and being written from the crew’s point of view it provides a valuable perspective of why we need ‘flying’ to go just right.

“If the microburst encounter happened at any lower altitude or if there was any lesser crew response, then the resulting aircraft flight path could have led to a major accident.”
“Follow recommended procedures to give the optimum performance. Practice an encounter with the FAA level 4 windshear in the simulator.”
“Severe wind shear or micro downburst conditions can occur near any cumulus clouds; they are not limited to Cb clouds.”
“The most significant yet unusual warning of the encounter was the crew's awareness of the exceptional noise of very intense rain.”

Note that the conditions did not involve a Cb, just a big Cu and that the met report was 'light rain falling at the airfield”; the WXR did not detect anything significant. The aircraft did not have windshear warning system, but a reactive system may not have bettered the Captains awareness, nor might a predictive system identify a rapidly developing hazard.
Also note what can be deduced from FDR analysis.

Windshear Incident (http://www.scribd.com/doc/35984283/Windshear-Incident)

“The probability of encountering a hazardous situation does not recognise age, experience, or length of service - if it can happen, it will happen; probably to you!”

“If you have been unfortunate to have a severe safety event you are not exempt from another!
Having had one event, it can lead to a consequential event.”

[Capn Bloggs]

Is this the standard method on the 738?
Different aeroplane, but same principle. Sorry for the confusion. Wait for it, we disengage the AP and leave the A/T in. My original point on the use of FPA was in relation to India 42's comment re the approach slope on the chart.

The most significant yet unusual warning of the encounter was the crew's awareness of the exceptional noise of very intense rain.
That is a good one to store away.

The coded E/D on this approach is at MA09, not at 50' over RW09...surprise .
I never said there was a RW09 waypoint at 50ft. All I said was that I assumend the approaches are designed to put you at 50ft TCH over the threshold: vertically speaking only. Obviously, laterally speaking, the approach must be offset.

If MDA 470 is set in the MCP (new RC A/P will accept this)
Catching up to the real world. :D

[BOAC]

PEI - the 737-6-900 have both predictive and reactive windshear warning systems.

OK - your penultimate para is a little concerning given the prevalence of 'magenta-line kids'.

[repariit]

"Who will be examining the FDR and CVR and is there any chance of shenanigans?"


The Brits at Farnborough did it for a previous Lion crash in Indonesia, but I have found nothing in the news on this one. I do not recall another crash where it was not reported along with the recovery of them.

[PEI_3721]

BOAC, re “… a little concerning given the prevalence of 'magenta-line kids'.” (#487)
Yes; IMHO the example incident (#484) shows that even with experience (which may take at least 10 yrs to accumulate) there are some situations where all experience, quick and accurate appreciation of the situation, and correct action, are required to avoid an accident.
The human aspects in accidents appear to be a problem of continuing assumptions in regulation, where in a few rare and extreme occurrences the human is expected to manage. However this assumption may not now be valid throughout the industry, particularly with reduced opportunity to gain the required level of experience.

This evolving problem may originate with selection and training standards, which appear to be in decline, or that the regulations expect too much of human capability given the current professional and social cultures; instant gratification, weak attention span, a Google-its knowledge base, etc, etc, and ‘follow the line’ (SOP-its, use autos / FD / computer generated answers).
Thus what appears as human weaknesses in operation – ‘why weren’t threats and errors detected/avoided/mitigated’, are artefacts of the industry’s expectation. Thus the industry should perhaps not have such high expectations, limit operations, and provision aids to help the human; e.g ground based wind-shear warning and precision approach paths.
Note that in the example incident (#484), the crew generated an altitude/range model for their NPA; the Bali approach chart does not have a range/altitude table.

[PJ2]

Exceptional observations, PEI_3721.

PJ2

[lederhosen]

Those suggesting weather cannot have played a role should read the the report linked in PEI's most informative post.

I do not however agree with comments from others that Lionair's role in eroding terms and conditions and its safety culture should be ignored. I know people who have worked at Lionair. They are highly critical. These pilots may have been experienced. But anyone unaware of a problematic safety culture is not terribly well informed.

The facts should be known soon enough. But the possibilities include:
1. Something on the airplane failing....brand new plane and not much indication in that direction.
2. Act of God, weather exceeding the capability of the aircraft....cannot be excluded, but unlikely to be the only cause
3. Pilot error.....never very palatable for fellow pilots, but more often than not a factor

If there was pilot error combined with deficiencies in safety culture then the cost of insurance for their huge new fleet will probably increase. Given nobody was killed it will not be such a big insurance event. However it is indicative of what could happen.

Hopefully this will make the management of Lionair and other airlines, who consider pilots an expensive and largely avoidable cost, stop and rethink how they recruit, train and retain their pilots.

[sevenstrokeroll]

The CVR should be able to pick up the sound of the rain to prove or disprove some reports of a wall of water.

IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.

[Herod]

Just watched "Children of the Magenta Line". That should be required viewing on all training courses on a modern aircraft. In my last job we had a lot of
P2F First Officers, which made us effectively unpaid line trainers (although I have to say that since these were not strictly company employees, we had a "spare" FO sitting down the back). Even flying over Europe a question such as "if an engine failed now, where would you go, and why?" could leave them floundering. I never tried "if I were to die now...? The answer would probably have given me sleepless nights. Enough thread drift, just wanted to put my bit in.

[lomapaseo]

The CVR should be able to pick up the sound of the rain to prove or disprove some reports of a wall of water.

IF the noise of the rain was of a high decibel level, we may also find out that the crew may have had trouble talking to each other with proper flight discipline lost.



On past engine wash outs it wasn't the rain that you hear on the CVR it was the hail.

Rain alone is not the problem as it gets centrifuged out the fan, The problem is the inertia of the hail which overcomes the centrifuging effect.

In order to do it with water alone you would need extremely low engine rpm and a rain storm of the likes never documented in a flight encounter.

I don't mind all these various what-if theories being expounded here as long as we accept the investigation findings when they are released.

[sevenstrokeroll]

lompaseo

who said anything about an ''engine wash out''? I said we would hear rain on the CVR if it was of such amazing intenstiy as to be classified as a ''wall of water''.

We would also hear the windshield wipers going like HELL.

I've been in the cockpit of a 737 while it was raining (not hailing) and the noise level was higher than normal...adding the windshield wipers and even a hollar for rainboe would add to the noise.

lets not read too much into a simple statement.

this would be an excellent accident to have a cockpit VIDEO recorder to aid in investigation.

[smiling monkey]

Insider info :

F/O selects FLAPS 15 passing the MDA, without go-around command (that's explain the "drag down from the air" claimed by PIC).

If this is infact true, then that explains a lot of things. And IF true, how then can a 2000 hour FO not understand the consequences of doing such a thing, so low to the surface and at a relatively low airspeed?

[sevenstrokeroll]

monkey makes a good point...remember the FO retracted flaps in the colgan crash near KBUF...

[ExSp33db1rd]

Just watched "Children of the Magenta Line". That should be required viewing on all training courses on a modern aircraft.

Totally agree.

Even on the so called 'advanced' microlights - LSA's in USAspeak - that I now instruct on, many are coming fitted with TV screen style, Glass Cockpit, instrumentation, and students spend far too much time gazing at the picture - actually trying to find the basic information like airspeed and altitude from amongst the mass of largely uneccessary information that is also there - and not enough time looking out of the window, some even bring their own iPad loaded with some sort of Magenta Line navigation software.

Our CAA Rules for microlights only require a means of determining Airspeed, Height and Magnetic Heading, so with all this superflous electronic information we are already breeding a new generation of pilots, and many of our students start their eventual airline career on these little aeroplanes, dependant on all this electronic gadgetry.

I refuse to allow iPads when I fly with them, and am clearly regarded as a Mean Old Fart. I also ban cellphones now, after one student started texting his girl friend whilst taxying back in, before completing the After Landing Checks ! Perhaps I am a MOF ? See if I care.

[Toruk Macto]

Its been reported that the cpt had a training background but is he a company trainer ? The F/O has 2000 hrs , assume he started with company as P2f at 200 hrs then he may be coming up for a command himself . Maybe there was some command training or command potential checking going on ? Be interesting to read if there where any CRM issues that contributed to the outcome .

[DozyWannabe]

monkey makes a good point...remember the FO retracted flaps in the colgan crash near KBUF...

True, but in her defence she was sick enough that in any other industry her manager would have sent her home the second she walked through the door - and that's before we get to the question of fatigue. Sure, the pilot error aspect of that accident was inescapable, but the real can of worms it opened was an ops culture that bordered on lunacy in any objective sense of safety concern.

Even on the so called 'advanced' microlights - LSA's in USAspeak - that I now instruct on, many are coming fitted with TV screen style, Glass Cockpit, instrumentation, and students spend far too much time gazing at the picture - actually trying to find the basic information like airspeed and altitude from amongst the mass of largely uneccessary information that is also there...

It's not that hard to find - you can turn the "extraneous" stuff off if you want and you have basic instruments right there. Sure it looks different from the steam gauges you grew up with, but it's all the same under the hood. If they're struggling then they didn't do their homework. If you want them to look outside, would it be that hard to tell them to do so and assure them you'll monitor the instruments for them while they get used to it?

I refuse to allow iPads when I fly with them, and am clearly regarded as a Mean Old Fart. I also ban cellphones now, after one student started texting his girl friend whilst taxying back in, before completing the After Landing Checks ! Perhaps I am a MOF ?

Nope - there you're absolutely in the right, because they're supposed to be learning, and that kind of distraction is bad news.

Look, as I understand it the "Magenta Children" meme is basically a treatise on *automation* dependence, not an avenue for bashing modern avionics in general. A PFD - even on a microlight - is just a modern iteration of the old-fashioned gauges. If you only want it used as such, then there's nothing stopping you.

[sevenstrokeroll]

dozy...

I'm in the airline industry...all the colgan FO had to do was call in sick. granted, an outfit like colgan might have tried to fire her, but it was her choice to fly.

and that is what leadership is all about.

I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.

[DozyWannabe]

I'm in the airline industry...all the colgan FO had to do was call in sick. granted, an outfit like colgan might have tried to fire her, but it was her choice to fly.

We may differ in our interpretation, but your second sentence reads to me like coercion by any other means.

and that is what leadership is all about.

Forgive me if I'm missing something, but I don't see how being willing to risk your job and chosen career path if you call in sick has anything to do with leadership.

In any case, the illness and commuting fatigue factors combine into a potentially deadly whole if you consider that with a flu virus you can feel fine when you sign on and deadhead from Seattle, but feel like death when you get off at Newark.

Of course, you can call in sick at Newark, but then we're back to coercion because you not only have to pay your own accommodation costs - being very far from home - but you'll probably have to front any further transport costs to get you back home and lose money on your flight time. That's on top of the question you raised of whether doing so would risk your job.

I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.

In all fairness, I suspect your salary was a much better deal than that now available to junior FOs working for the regionals. Combine that with the fact that your union representation was much stronger back then and I hope you can see that it's not a valid comparison.

[aterpster]

sevenstroke:

I will also say this...after commuting from San Francisco to Boston, I learned early on that I had better get there in time to have 12 hours in a hotel before reporting for duty...and it cost ME money.

I guess it would have cost her money, too, which I doubt she had.

I got displaced from LAX to STL for 4 months in 1983. I went over the day before for an 18 hour, or so, layover on my dime.

Even then, it finally caused me issues, which proved what I knew all long, that I couldn't commute from LAX to JFK to fly the "coveted" international (when it was far more limited.)

[sevenstrokeroll]

dozzy...I suspect that you really don't know flying well.

the FO made a choice of living in SEA and flying out of EWR...and if it didn't work for her, she could have gotten a ''crash pad'' instead of living at home...or she could have waited for a job with another airline in SEA.

I remember what I went through when i worked for regional airlines...and I remember quitting one that had the habit of flying over gross weight.

You rarely ''get it all''...if I got it all I would have had a job in SFO instead of BOS...but I knew what it would cost me in terms of money, relationships and everything else under the sun.

AND if she was so sick, why was she well enough to explain in some detail how she had an "IN" at another larger airline and would likely get on there while the crew was flying through the night?

No Dozzy...the world of the pilot is pretty well known by the time you have as many hours as she had.

aterpster...I understand...I also know how I gave up a captain slot at a regionalairline in MSP to stay closer to home for money, family and other situations.

money...its all about money...choices...that's what flying is.

[PJ2]

Dozy, ExSp33b1rd, the problem is way deeper than gazing at the guages for information.

We have slowly built a virtual world in which software and the enticing and even intoxicating, (in-toxic-ating, if we take the root word) images formed by billions of pixels may just present information but this way of replicating the outside world is making a fundamental shift in psychological and sensory perceptions; they have grown into substitutes for what is going on outside the cockpit. We accept that what we see on the screen is not only more accessible but "more" accurate. Prior to automation it was easy to perceive that what was presented on the guages coincided with the world beyond the cockpit. Today most "piloting" is done "inside the cockpit", (so to speak) and because cockpit information is so rich, so ergonomically good and reliable, the need to "verify coincident information", (by which I mean, attend to understanding what is going on outside...beginning with the wings and engines and extending to weather systems), is less.

Steam guages always elicited a slight suspicion not wholly justified, because they got very good but remained unchanged until the early '80's. But the nature of reading, interpreting and flying the "group of six" is fundamentally (and philosophically, if anyone cares) different in the way our mental model of the outside world is structured and reified.

The effect is a disconnect between what is merely seen outside the cockpit and what is psychologically perceived outside the cockpit.

Many Old Farts, (and I'm one of 'em) may struggle with this notion and even dismiss it, but in my view no one under the age of 30 probably would. In fact, it is likely that none of this is visible to them - they are "in the river" so to speak and can't see the movement that has occurred in the tools of their trade.

Under the heading of, "I'll see it when I believe it . . ." we we old farts see the world fundamentally different. It is why skills, particularly manual skills, are yielding psychological space to skills which require the manipulation of a virtual world which more thoroughly than ever, is the model of reality we carry in our heads.

One is never in a cockpit, one is in a virtual reality, the presentation of which is on screen. That is a state of mind that a group-of-six could not possibly achieve. "Virtual Reality" is actually an oxymoron but fewer and fewer intuitively know this, (or experience the difference that makes a difference).

I know this is a topic for another thread and my apologies for the momentary thread drift. But there is a qualitative difference in recent accidents even just within the field of human factors and it shows up primarily in CFIT and LOC accidents. Control is lost or a CFIT occurs in perfectly serviceable aircraft because the real reality when the virtual reality implodes when the screen reality for some technical reason, disappears. I think this is what is going on when we speak of "children of the magenta line"; - there is simply less experience in reality to fall back on when the software or the guages quit.

The F/O on the Colgan Q400 accident at Buffalo was texting on the taxi-out. It's what people under 30 do and it was "normal" for her. The sad thing is, no one at her airline told her how to be a professional airline pilot and her captain just let her continue. We have to teach those who don't know that aviation still kills regardless of how much information we have on our guages or screens or tablets.

So ExSp33b1rd, well done and good for you for keeping the iPads, cell phones and other 'virtuality'-creating devices out of the cockpit, at least until your students understand that an accident is not virtual.

PJ2

[Capn Bloggs]

I already have one of your previous posts cut-and-pasted to my computer, PJ2. The one above will be the second. :D

[DozyWannabe]

@PJ2: Very interesting stuff, and food for thought. I'd like to ruminate for a bit and reply properly tomorrow, but I'm not sure this thread is the place to do it, as we're off in the long grass topic-wise. Your post might be worth a thread of its own in fact...

[jcjeant]

Hi,

One interesting thing is how you can learn to write
There are currently two ways (since the invention of the typewriter .. now shelved and replaced by mechanical keyboard or touchpad)
Can a child learn to write using only the keyboard
Or you can learn to write with a pencil
Whoever has learned to write with a pencil can easily immediately write with a keyboard
Whoever has learned to write with a keyboard will be a lot of trouble to write with a pencil
To meditate .... :)