Lionair plane down in Bali.

[sabenaboy]

In post 724 (http://www.pprune.org/rumours-news/512476-lionair-plane-down-bali-37.html#post7816806)Look for the NTSC to publish a preliminary report here (http://dephub.go.id/knkt/ntsc_home/ntsc.htm) by May 13th.

Nothing there yet! :{

[repariit]

In post 724 (http://www.pprune.org/rumours-news/512476-lionair-plane-down-bali-37.html#post7816806) Quote:
Originally Posted by repariit
Look for the NTSC to publish a preliminary report here (http://dephub.go.id/knkt/ntsc_home/ntsc.htm) by May 13th.

Nothing there yet! http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/boohoo.gif

The "preliminary report by May 13th" was an NTSC response to an email that I sent to them asking when they would publish something. I sent a follow-up two days ago, but have not seen a reply yet.

[repariit]

The preliminary report is now posted here (http://www.dephub.go.id/knkt/ntsc_home/ntsc.htm). It does not say why they crashed. The PF said he could not see the runway at 150 feet AGL, and the Captain took over. It appears that either the GA was initiated too late or not at all.

[nitpicker330]

So, minimums call at 550'. Continued down without seeing the runway, 150' the Captain takes over as the FO says again he can't see the runway.
Aircraft gets down to 20' before the Captain calls Go Around.......hit the water 1 second later....

They flew a perfectly serviceable 738 into the water for no good reason......

The mind boggles........:\

Lucky they hit the water where they did, another 100' closer to the runway and they'd all be dead after impacting the sea wall.......
So I suppose you could say they were lucky!!:eek:

[Ollie Onion]

Good Lord!!!

So at 900' the PF states that 'he can't see the runway' and they continue to minima which is fine. At minima the A/P and A/Thr disconnected and aircraft continues to descend (dodgy), then at 150' the PF once again states that he can't see the runway so the Captain takes over and continues descending to 20' where he realises that he maybe should go around........ UNBELIEVABLE :\:\

Seems all very casual, no mention of a visual call at minima, assumption would be that they weren't, they then pushed on regardless to a position in the water well short of the runway which they hit with ultimate precision.... IDIOTS

[autoflight]

Flying experience
Total hours : 15,000 hours
Total on type : 7,000 hours
Last 90 days : 279 hours 8 minutes
Last 60 days : 20 hours 51 minutes
Last 24 hours : 5 hours 11 minutes
This flight : 1 hour 50 minutes

The captain flight time between day 90 and day 60 seems a touch on the high side and should have been a red flag for the preliminary accident report. Does the NTSC think that nobody is going to read the report? Or have I been wearing my old glasses when I read it?

[ATC Watcher]

Confirming many points heard in Bali, but leaving some other unanswered.
The airline (and Capt ) explanation that it was a micro-burst and that despite applying full power a/c continued to descend is seriously shaken by the CVR transcript.(as expected ) No Chances anymore for the Boeing award I would say.

Continuing descent below MDA without runway in sight on a non-precision APP seem to be the main cause.
The fact that the a/c was never aligned with the runway is confirmed , but not explained.

[nitpicker330]

They never had the Runway visual and the LNAV was probably faithfully following the inbound VOR radial. The inbound course is 091 whilst the Runway is 087. It's not aligned.

[PJ2]

that despite applying full power a/c continued to descend is seriously shaken by the CVR transcript.

Scrawny details, nothing of substance in this work.

Where is it indicated in the flight data that "full power" was applied?

Until the recorder provides the data, such statements are only hearsay.

In my view, at this important juncture the report is an embarrassment to ICAO requirements and the accident investigation process.

PJ2

[nitpicker330]

1/ this is a preliminary report
2/ what in the report is wrong?

They mention the Captain called Go Around 1 second before "landing" on the water whilst at 20' RA……. a bit late…..:eek:

Forget about full thrust, it never happened….:ooh:

[mm43]

RoD wasn't being monitored, and even though the PIC started a GA, if at this stage of the doomed Flight Path he'd commenced say 3 seconds earlier, the outcome would have been worse. Yeah! The embankment would have been painted red.

These guys and all those in the back were very very lucky.:\

[sabenaboy]

Here is a direct link to the preliminary NTSC report (http://www.dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary_Report_PK-LKS_Lion_Air.pdf).

[sabenaboy]

According to the report the captain flew:
Last 90 days: 279 hrs 8 min
Last 60 days: 20 hrs 51 min

That would mean that between -90 and -60 days he logged 258 hrs and 17 minutes in 30 days!! :ugh:
Surely that can't be true! Or can it? Please tell me it's a typo! :eek:

[Checkboard]

They flew a perfectly serviceable 738 into the water for no good reason......

Fuel isn't mentioned anywhere in the report. Not enough fuel to fly a missed approach would be a good reason to continue.

(Yes, I know, there is no good reason to run out of fuel, and Yes, I know, there is no information that fuel was an issue. :rolleyes:)

1.4 Other Damage

There was no other damage to property and/or the environment.[My bold]

[1a sound asleep]

Unreal. Lets decide to do a go around at 20 feet. It says everything

[fox niner]

Dear god.
If this report turns out to be more or less factual, then there really is NOTHING that i will learn from reading it.
Outrageous, (almost) criminal recklessness....

[crwkunt roll]

that despite applying full power a/c continued to descend is seriously shaken by the CVR transcript.

No sh1t..........Full thrust at 20 feet AGL just gets you to the water faster.

[Yaw String]

Lionair...what is it that they have written on their 747's..

"we make people fly"!

A correct statement It would certainly appear to be, if their pilots are proved to be exceeding flight time limitations.
And from now on it may have to apply to their passenger marketing strategy.
:=:=:sad:

[despegue]

IF the preliminary report is correct regarding flight hours, then the Lionair AOC has to be revoked with imediate effect.

This accident absolutely beggars belief. IF they had no contact at (m)DA and continued, with a decision to go around at 20 bloody feet, then this is one of the most unprofessional and unnecessary crashes ever. No unintential mistake but attempted mass murder.
I sincerely hope that this report is incorrect and we are missing the causal factors of this accident.

[ATC Watcher]

Just for the sake of not being misquoted ad vitam...
when I wrote :that despite applying full power a/c continued to descend
This is what the Capt had apparently told his management after the accident.
He did not say how high he did do it. The Report does not tell us either. It only mention a CVR remark to go around at 20ft . one second before impact.
The FDR print out on page 21 does not include engine parameters unfortunately..

[camel]

and if it all goes ti.s up : 'we send people to the best hospitals ' aha thats ok then eh?:uhoh:

[safetypee]

It may be worth comparing the latter stages of the approach shown on the FDR trace (link #780) with that of this Windshear Incident (http://www.scribd.com/doc/35984283/Windshear-Incident)

Note the changes in GS, ASI, and VS. Any conclusions from this might also reflect on aspects of surprise, attempting to understand a rapidly developing situation, change of PF, and thus potential for distraction and reduced attention to normal flying practices.

[framer]

The AOC should be revoked, but it won't be because there is too much money greasing the palms of the Indonesian officials. The regulator is responsible to the Indonesian public to provide a safe industry but fails to meet that responsibility.
Nothing short of manslaughter if allowed to continue.

[Sir Richard]

The hours referenced to 90 days and 60 days would make more sense if it was 90 days and 7 days for both the Captain and his Copilot.


Posted from Pprune.org App for Android

[Heathrow Harry]

framer wrote:-
"The AOC should be revoked"

surely a bit OTT for a single incident? We wouldn't have many airlines around if we adopted that attitude

[Jet Jockey A4]

Because of what appears to be an incompetent crew...

1- Well if the flight hours at 60 days and 90 days are correct then they have a major safety issue.

2- Not "going around" at MDA with no runway in sight is another major safety issue.

3- Waiting to take over the controls at 150' AGL is another (IMHO) safety concern. Why not just instruct the PF to "Go around"? Why wait so long in the first place?

4- Waiting until 20' AGL before "deciding" to "Go Around" and apply GA power is well "too late" and the crash was now unavoidable.

Not typed on a B737, but why was the auto throttle system disconnected at the same time as the AP at minimums? Can you not have the ATs working for you on the B737 with its AP off?

I thought it was mentioned and perhaps confirmed on here by a pilot that the F/Os could not fly the aircraft below 5000 feet at this airline because of past incidents/accidents. If true this is another breach of company SOPs.

In any case this company as a bad track record and I would'nt fly on them.

[Alew Crew]

From 900 feet AGL to the minima descent altitude was 465 feet AGL, the crew continued his approach. However at 900 feet, the Pilot Flying (First-officer) reported the runway was not in sight.
At 465 feet, we can expect the visibility was enough to continue approach.
As the report say, at 150 feet PIC took over control of aircraft... What does it mean really ? Does the captain realise the aircraft was in bad conditions to assume a safe landing ? And obviously, perhaps does he think " I should have had to apply full trust to make another approach ? "

According to me, at 465 feet, the crew should have ordered a go-around.
Just behind another aircraft was forced to proceed a missed approach due to the poor visibility at the MDA.

I'm french and i hope my english is enough correct ! Please if you see some grammatical mistake let me know ! thanks Guys ;)

[captjns]

What a pity. Needless incident by an incompetent crew.:*

[PJ2]

nitpicker330;
1/ this is a preliminary report
2/ what in the report is wrong?
A preliminary report is supposed to provide some early sense of accident causation or at least outline the factors which may have contributed to the accident. It is supposed to provide as much information as is available, normally from the data recorders, for the various user-communities to understand what occurred to that it can be prevented from happening again.

This "report" provides none of this; it is insufficient to understand what actually occurred.

There is nothing "wrong" in the report - there is nothing of substance in the report with which to be wrong.
Forget about full thrust, it never happened….
Other than hearsay, from whom or where does this information come? At this stage of an investigation, that kind of information no longer belongs in the rumour or witness category, it belongs in a preliminary report as derived from the data recorder(s). But there is nothing in the report that discusses power, nothing even to say it was, or wasn't applied, nothing that discusses any kind of go-around decision, nothing that discusses whether the airplane actually stalled in or was just flown into the water; the report does not discuss either pilot taking any preventative action.

That is why I think that the preliminary report is both insufficient and inadequate.

[lomapaseo]

The decision to go-around at 20ft with no runway in sight is not the problem that needs fixing.

The failure of the PF flying to react to the lack of runway in-sight with a go-around from a safe altitude needs fixing, as well as ;


The second more senior pilot accepting a handoff at an unsafe condition without calling an immediate go-around.

It took two grevious early human errors as a cause and the decision to go around at an unsafe altitude was a result and not a cause.

[safetypee]

PJ re nothing of substance, see #790,
Re FDR Trace, around 07:09:05, split between air and ground speed then increase in airspeed.
VS previously steady at 600ft/min, deceases to 400 then increase to 900-1100ft/min, at the same time as oscillating pitch and roll, generally towards nose up, then nose down.
Comparing this with the previous incident one might deduce a rapid onset downdraught, even a micro burst windshear.

[smiling monkey]

I understand this is only the preliminary report but I do hope that the final report will mention whether the crew was actually visual or not at the MDA. Many here are assuming that just because the PF mentioned runway not in sight at 900 ft, he was also not visual at the MDA. There is no mention of this in the report. They may have become visual between 900 ft and MDA but then lost it again below minimums due to heavy rain.

I do recall a similar incident in Bangkok around 1999 where a Qantas 744 lost visual reference with the runway just seconds before touch down. If I remember correctly, the F/O who was flying initiated a GA, but the captain cancelled it when the wheels actually touched the runway, resulting in an overrun.

Another matter of concern is why there is a 'handing over' of the controls from the PF to the PM at such a critical phase of flight? Did the captain simply took over control because the PF didn't initiate a go-around? Or is it Lion Air SOP that requires only the captain to perform go-arounds? Or did the F/O simply handballed the controls to the captain because he wasn't competent enough to handle the GA himself? I hope these questions will be addressed in the final report.

[BOAC]

Based on gossip here about F/Os in Lion and what they can and cannot do, I would suggest the Captain probably does the landing (.........and normally on the runway...)

[gazumped]

The first of three recommendations of the NTSC is an absolute ripper!!

Words to the effect of "....Pilots are reminded of the importance of carrying out a missed approach if visual reference is not obtained by the minima...."
Some wise old pilot once told me that there are only 2 golden rules in aviation Lowest safe's, and Minimas.

The first rule NEVER go below LSALT unless you are visual, (councils never give building approvals to build anything above LSALT's!!).

The second rule NEVER go below minima's unless you are visual, if you reach the minima and it is not "Bank of England Safe" go arround like a golf ball bouncing off concrete.

What a sad unnecessary waste of an aircraft. Absolute pure dumb luck everyone wasn't killed. It will be interesting to see what the Indonesian authorities do to clean up this mess.

[pattern_is_full]

VS previously steady at 600ft/min, deceases to 400 then increase to 900-1100ft/min, at the same time as oscillating pitch and roll, generally towards nose up, then nose down. Comparing this with the previous incident one might deduce a rapid onset downdraught, even a micro burst windshear.

The change in average VS, from ~700 fpm to ~1000 fpm, coincides exactly with the PF going to "manual control" at 550 feet. As does the consequent steepening of the glide path (Figures 2 & 8) - which then remains more or less constant at the new angle until end of chart. Looks to me more like pilot input (intentional or unintentional). Microbursts usually result in accelerating downward VS, rather than a single change from one steady descent rate to another.

Note the steepening curve in your own wind-shear example.

(The same for the onset of less stable flight in roll and such - face it, autopilots are often steadier than human hands. ;) )

In a wind-shear event, I'd expect some germaine CVR comments (based on what usually is heard in such events) - along the lines of "WTF!!? POWER POWER! Pull the nose up!"

But a full second-by-second CVR transcript is exactly one of those elements missing from this prelim report.

Always remember that the scientific approach to an investigation is not to ask "What evidence here is consistent with wind-shear (or other theory)?" - but "What evidence here is absolutely inconsistent with anything except wind-shear?"

I do hope that the final report will mention whether the crew was actually visual or not at the MDA. Many here are assuming that just because the PF mentioned runway not in sight at 900 ft, he was also not visual at the MDA. There is no mention of this in the report.

Exactly. Absence of evidence is not evidence of absence. We just don't know - yet.

[PJ2]

safetypee;
Re, ". . . one might deduce a rapid onset downdraught, even a micro burst windshear."

Yes, possibly.

Some thoughts on the data made available and the possibility of windshear.

First, we don't have wind direction and speed parameters, engine thrust parameters or any of the autopilot controls, (heading selection, FPA-VS selection, airspeed selection).

We don't know if the non-precision approach was being flown using "selected" autopilot values for the airspeed and FPA (or VS), or if it was a "managed" (Airbus terms, I know), approach being flown automatically through the FMC.

Therefore we can't say for sure whether the variations which occur in pitch, FPA, VS, airspeed just prior to the autopilot disconnect are a result of such selections or a result of environmental factors.

The variations in airspeed, groundspeed, pitch, roll, VS / FPA prior to and even after AP disconnect, are relatively minor and well within an energy envelope that would counter windshear.

The autopilot was disengaged (as indicated by disengagement of VNAV / LNAV modes) at 07:09:23 just below 600ft RA.

At about 07:09:11, at 750ft RA, the pitch reduces from 1deg NU to 2deg ND. At the same time, the FPA shows a reduction from -1deg to - 5deg and the airspeed and groundspeed concurrently increase.

The difficulty with a windshear theory is, no attempt was made to increase pitch beyond 2deg NU to arrest what became a 1000fpm VS. We don't know if thrust was applied or not because the engine parameters have not been included in this report.

However, microburst or no, the immediate key in this CFIT accident is the captain's decision to continue the approach, a) after the F/O reported that he could not see the runway and, b) after the captain had taken over and he himself reported at 150ft that he could not see the runway.

A go-around from 20ft is usually successful providing one is aware of two things:

a) engines must be spooled for immediate response, and,
b) it is likely that from a low-energy, low-altitude go-around, the airplane will momentarily touchdown on the runway before continuing.

This certification requirement & qualification caters to CATII & III low-level go-arounds where momentum of the airplane will continue the descent for a few seconds. This is also the reason many countries have added 50' to any non-precision approach minima - to cater to a slight loss in altitude should a go-around decision be made; it keeps the aircraft (and the crew) from busting NPA minima.

Anyway, there's not sufficient information to do other than continue guessing what this crew was doing and why and what both the Lion Air, and the NTSC response may ultimately be.

[Tamanrasset]

Apparently, the crew had the runway in sight at MDA and this would be on the CVR. If confirmed, the first recommendation might not be that justified.
Go around could have been decided earlier when the sink rate was higher than 1000 ft/mn and the approach likely to be destabilized.
Initiating a goaround on short final would have been a better idea from the copilot than giving the controls back to the captain.
It seems to me that the report wants to underline potential issues with the procedures when the problem might be somewhere else.

[Oakape]

Not typed on a B737, but why was the auto throttle system disconnected at the same time as the AP at minimums? Can you not have the ATs working for you on the B737 with its AP off?

Jet Jockey A4, it is Boeing SOP to disconnect the auto throttle when the autopilot is disconnected, which is the procedure most operators seem to use. However, some operators use a slightly different procedure, in that 'speed' mode is deselected on the MCP & the auto throttle remains armed.

[413X3]

So low time pilots are the danger in the skies? Another preventable crash where thousands of hours of experience seemed to mean nothing.

[de facto]

If they were at flaps 40,retracted to flaps at 15 at 20 feet when the speed may be below vref and a sluggish increase of thrust then...well..

[MountainBear]

Therefore we can't say for sure whether the variations which occur in pitch, FPA, VS, airspeed just prior to the autopilot disconnect are a result of such selections or a result of environmental factors.Yes. The FDR makes it obvious that something happened in the 60 seconds before crash but it is not at all clear what caused it. The people who are leaping down the pilots throats are jumping the gun. Sadly, this is not unexpected given the lack of data here: more guesswork filling in the blanks

b) after the captain had taken over and he himself reported at 150ft that he could not see the runway.Is that correct? I read the report as saying it was the SIC who stated he could not see the run way, both before and after handing it over to the Capt.

[nitpicker330]

1/ They either had the required visual reference ( in this case Runway threshold in sight ) at or about the minima then lost visual,
or 2/ they never saw the runway at all

Either way it Doesn't absolve them from the stupid act of flying a perfectly serviceable Jet into the water.......

If they were visual and landed in the water they are even more incompetent than words can describe.

The only, and I underline only excuse would be a Windshear or Microburst at or after the minima that they could not recover from........

[MountainBear]

Anyway, there's not sufficient information to do other than continue guessing what this crew was doing and why and what both the Lion Air, and the NTSC response may ultimately be.And we may never know. I have thought of a scenario that fits the facts in the report and yet may not subject to falsification.

(1) The SIC (PF) notes that he cannot see the runway at 900'
(2) Sometime between 900' and MDA there is a window in the weather and at MDA he can see the runway.
(3) They get hit by a microbust and their VS increases by almost 1000 ft/min. However, this goes undetected for two reasons. 1) they are concentrating on keeping the runway in sight and 2) at this stage in the flight a micro burst would be deceiving because they are landing. It drives them in the direction they expect to go, down.
(4) The SIC loses sight of the runway again.
(5) The PIC senses something is wrong so he takes the manual controls. Now, the startle factor is in play. The plane is descending much faster than he is used to. Someone back in the thread stated that the PIC said that a big force was pushing him to the ground. If this comment is true that suggests he is feeling the high rate of descent from the microburst that is already over (and which has gone undetected.) The PIC now has some serious cognitive dissonance going on because he has two competing priorities 1) where is runway? and 2) why does the plane feels like it is falling too fast? By the time he resolves this test in his head and calls for a go around it is too late. It is worth pointing out that this delay in dealing with a startle effect is exactly the type of thing one would expect to see in a person suffering fatigue, especially cumulative fatigue.

The problem with this scenario is is that even the engine data might not be too helpful. It is only going to tell how the crew responded to events and not what caused those events. One might be able to tease out some data regarding how much of the descent in the flight path was a direct result of pilot command vs weather related. But they didn't miss the runway by much and one might run up against margin of error problems in the engineering data. In may be that the final report is no more illuminating than the preliminary report in this regard.

[nitpicker330]

You do realize that the FDR records all data don't you?
IAS TAS HDG TRK GS W/V SAT TAT IRS position.......plus hundreds of other systems......
If there was a Windshear or Microburst THEY WILL KNOW.

The SIC never called Visual at the minma, the Captain never said anything at the minima.........

Does that tell you anything????

It tells me that the PIC flew the a/c below the minima without visual reference hoping the runway was in the right place ........at 20' be realized there wasn't a nice runway under him........tooooo late.

[MountainBear]

It tells me that the PIC flew the a/c below the minima without visual reference hoping the runway was in the right placeSuspicions are not evidence. :ugh:Absent an actual statement from the crew, we do not know what they saw at MDA.

If there was a Windshear or Microburst THEY WILL KNOW.


Putting you point in all caps doesn't make in any more convincing.

[gazumped]

Mountainbear,
Your point 3) the vs didn't increase by 1000 fpm it increased to 1000fpm, anything greater than 1000fpm is by definition unstable and requires a go-around if below 500'.
1000 fpm on final is not completely unusual, but it is on the limit, but OK to continue. The 737 800 has enhanced EGWPS, with predictive windshear, both systems to avoid WS microbursts, the wind on the ground was 120/6, although there was a localized shower in the area. Nothing on the FDR indicates microburst. When you have been in a microburst it is not something that gives you some vague feeling of unease, you very quickly know that things are not right, bigtime. The Lionair management made a statement before the wreckage was cold that weather played no part in the disaster, that is a very unusual thing to do.
bottom line, if a missed approach had been carried out when visual reference was lost @ 150 (something that must have been anticipated by the F/O's statement at 900'), we would be making comments on another thread.

[BOAC]

Anyone know what the unlabelled (mauve) 4th line down on the FDR plot is - N2?

[nitpicker330]

Mountainbear:-- I can't think of any other reason why they would fly into the sea!!!:confused:

In the absence of Windshear/Miroburst ( no evidence of such phenomena ) a competant crew wouldn't land in the water if visual and that leads me to say they must NOT have been visual. Or the Captain seriously needs glasses.:eek:

You can sugar coat it any way you like but them's the facts according to the NTSC. :D

[lederhosen]

The notes say magnetic heading with the line above DME distance and the line below pitch angle. It looks like the FO / pilot flying flew the non precision approach as you would expect using the autopilot. At MDA with or without suitable visual reference (but the latter seems more probable) the autopilot reverted to control wheel steering and shortly afterwards he flew manually.

The FDR shows the approach to have become unstable with pitch, roll and speed deviations. I am unfamiliar with Lion procedures, but at this point using any sensible procedures one of the two pilots should have called for a go-around. Handing over control at low level and finally deciding to go-around at 20 feet is clearly dangerously poor practice and led directly to the accident.

For whatever reason the co-pilot seems to have been way behind the aircraft. He was obviouly uncomfortable at not seeing the runway at 900 feet. Going below the MDA without disconnecting the autopliot is a violation of Boeing procedure. With the aircraft reverting to control wheel steering he was forced to take control, which the FDR shows he did poorly. Poor weather, poor flying, poor adherence to, or design of procedures, and the holes in the swiss cheese are lining up. The only amazing thing is that through pure dumb luck the attempted go-around resulted in a reduction in sink rate allowing everyone to survive. All in all it is a sobering indictment of just how bad things have got.

[nitpicker330]

Agreed, the FO may have been a poor stick and rudder Pilot after the minima but the Captain wasn't incapacitated, so what was HE doing as PM?????? Obviously not much... :D

It doesn't matter who is flying, the Captain is still responsible for the safe conduct of the Aircraft at all times. :ok:

[mm43]

@BOAC

Full size FDR Graphic (http://oi39.tinypic.com/34qussx.jpg)

[BOAC]

Thanks both - got my glasses on now. I had rotated the image and not scrolled fully right :ugh:

[framer]

When you have been in a microburst it is not something that gives you some vague feeling of unease, you very quickly know that things are not right, bigtime
Too true.
For whatever reason the co-pilot seems to have been way behind the aircraft.
How about because he had 1200hrs total time. 900 of which were spent sitting beside people who had a different language and culture while he was not permitted by SOP's to fly the aircraft below 5000ft. How on earth could he have developed a scan let alone good stick and rudder skills under those circumstances. There will be obvious mistakes made by the crew but the real cause, in my opinion, will most likely be decisions made by the company and the regulator.

[Tee Emm]

but the real cause, in my opinion, will most likely be decisions made by the company and the regulator.

That will be a relief to the crew that the crash wasn't their fault. That will get them off the dreadful hook of "Pilot Error" and permit them to continue their good work until the next accident...:ugh:

[lederhosen]

Framer you raise a good point. If Lionair copilots are not allowed to be pilot flying below 5000 feet as you appear to suggest, what on earth was he doing flying a non precision approach in poor weather? Although I am not a fan of captains doing all the landings, this accident does suggest why under certain circumstances it may be the least bad alternative.

Frankly even over here with a newish FO, (900 hours on type is about a year's experience at Lionair) I would have suggested under these conditions that it make more sense for the more experienced pilot to fly the approach.

This airline is definitely not one I would allow any of my family to use. 737 NGs have a pretty good safety record, but if you look at aircraft losses you come up with an interesting list of airlines. What it says about those airline's procedures, regulators and pilots you need to decide yourself. As I have droned on previously I hope the insurance industry will think hard about them too.

[Depone]

Quote:
For whatever reason the co-pilot seems to have been way behind the aircraft.

How about because he had 1200hrs total time...

And that may be true, however, the Captain bears responsibility if an approach is continued below minima without visual contact with the runaway regardless of who is PIC. This 15,000 hr Captain did not call/do a go-around until 20'RA.

As somebody mentioned, the crew appear to have left in the AP and followed the offset LNAV approach track all the way in, which is prima facie evidence that they never had sufficient visual contact to align with the runway.

[Avenger]

This is just another CFIT incident where a confused crew flew a perfectly serviceable aircraft into the water, had it been hard terrain they probably would have killed everyone on board. No CRM or bad CRM who knows, one could look at fatigue with average of 90 plus hrs for the PIC over the past 3 months, only 60 plus for the FO, however, looking at the weather, pics etc, there are no reasonable excuses for this nonsense. Initial recommendations may as well say " don't crash"

[MountainBear]

When you have been in a microburst it is not something that gives you some vague feeling of unease, you very quickly know that things are not right, bigtime.That is what one would think, yes. But fatigue does interesting things to the brain. Further, we do not know what training the crew actually had (as opposed to what they should have had) nor whether either pilot had ever experienced WS before.

The 737 800 has enhanced EGWPS, with predictive windshearThe preliminary report says that the EGWPS did not go off. Is this evidence, in your mind, that WS did not happen?

A question for any tech geek out there...if the FMS predicts wind sheer is that prediction recorded on the FDR?

[gazumped]

Mountain bear
They had a "windshear" just before the minima. The GS versus CAS indicate about a 9 knot headwind reducing to a 7 knot tailwind that caused an increase in vs and a steepening of the FDA and pitch angle, although the CAS appears to have increased. All of this does indicate a very mild windshear, absolutely consistent to a moderate shower, but it no way approaching something that would trigger a WS warning, and nothing that accurate hand flying would not have coped with.

The is also a very strong tendency to "drop" the nose when attempting to fly the aircraft by visual reference in very poor visibility( this is why bloggs tends to splonge in short of the threshold when attempting a visual approach when he shouldn't be). This is a manoeuvre that has been done many many times before in aviation history. Think of it this way, no one has managed to destroy an aircraft in a unique way in the last 50 or so years, they just keep doing the same dumb things. The captain should have been heard loud and clear saying Go around! Because of any of the following 1, unstable 2,loss of visibility 3 vs greater than 1000 fpm. The flight continued because there was an unshakeable belief that the aircraft was going to land successfully, after all isn't that what always happens?
There was no windshear, just very very poor hand flying, and very poor command judgement.

[alf5071h]

Avenger, #826. You post a glib narrow minded view representing older interpretations of ‘human error’.
If the crew were confused or exhibited poor CRM then what were the confusing factors, which aspects of CRM were weak, why? We might assume (with some confidence based on human nature) that the crew did not deliberately choose to fly into the sea, thus there could have been a decision making issue, a decision to continue, a decision of who and how to fly the aircraft, and when or not to go-around.

Until we have an understanding of the crews belief we cannot conclude anything for sure – gazumped how do you know that there was “unshakeable belief that the aircraft was going to land successfully”, the aircraft didn’t; thus a conclusion might be that there was a mistaken belief – the crew and your reasoning.
If we are to learn from these unfortunate accidents then the contributing factors have to be identified, even with speculation in advance of an official report there could be much to learn.

If windshear was a factor then perhaps predictive (radar) systems might not detect a rapidly forming or descending microburst (NB. AFAIR neither EGPWS nor FMS predicts W/S #827).
Crew’s might not experience ‘vague feelings of unease’ or interpret turbulence or change of speed with an impending threat; possibly factors of training or experience.
Why does disconnecting the autopilot from a VNAV approach apparently destabilize the flight path – are crews aware of this, what should be done.

There are lots of good points to be learnt, whether they apply to this event or not; our job is to learn and improve knowledge and hopefully be able to recall this and apply it when the occasion arises.

[noalign]

The FDR shows a good demonstration of an increasing performance shear, albeit quite small. The autopilot is pitching below the horizon, the flight path is ballooning, the airspeed is increasing, and the ground speed eventually begins to decrease. Of course the auto-throttles were probably reducing thrust too. Automation is not always your friend. Click, click, maintain attitude and slope, accept the airspeed excursion. Non-event.

The power lever angle and AOA traces would also be informative.

[gazumped]

The very simple reluctance to go around is well documented as a major cause of landing accidents. IMHO one reason for this is check and training concentrates on the difficult manoeuvres of V1 cuts, OEI missed approaches, raw data ILS etc, the garden variety multi mised approach is not practiced because it is so simple!
The other reason is the vast majority of approaches terminate in a successful landing, so therefore most crew come to expect that will be the case. When conditions conspire against the, especially when not expected, the chances of a landing accident increase. A version of "get homeitis", if you like.
Nitpicker330 makes a very good point, if the crew had visual reference then they just flew into the water(not likely). The only logical conclusion, supported by mild undershoot (via the published FDR, )is a lack of visual reference, certainly insufficient visual reference to identify profile decay. Hence a land short. When the captain recognised this it was far far too late. Any comment, and I mean any comment about runway unsighted @ 150 feet (unless conducting cat11or cat111) is call for an immediate go around. Scenario, if one of the crew members makes a statement that he can't see the runway, and the other crew continues, exactly what use to you is the unsighted pilot? He may as well not be on the flight deck. By contueing descent after that statement the unsighted pilot is rendered useless to you as a PM. Who in their right mind would willingly render their PM useless to them?
Two crew is two crew, and as such requires two brains two different points of view, believe me you want your PM to be on the ball actively monitoring, supporting, challenging you etc. when one crew member states" I can't see the runway" @ 150, that is as big of a red flag you are ever going to get.
If this scenario were in a simulator, and you could flight freeze the situation, and ask a couple of open questions of each crew member, then they would collectively decide that the only option at 150 feet was a go around.
We can all learn from this, because most crew in this situation usually end in up in the morgue and an interview is not possible. This crew are very very lucky, and their interview should reveal why they kept descending on an NPA without sufficient visual reference, and why oh why did they not carry out missed approach at the very latest @ 150 feet.

[alf5071h]

gazumped, #831, :ok:, yes I would agree with all of that, but there could be more.
IMHO failure to go-around is much more than ‘get home it is’; the issues are deep within decision making and a range of biases, including misplaced training.
‘I can’t see the runway’ is an important cue, but may not have to be a trigger to go-around if the airport environment is in sight. There is of course the risk of wish think, familiarity with the airport, or the assumption that it’s only a small shower where the aircraft will pop-out the other side, etc, etc, but only with hindsight do we judge an (in)action to have been ill chosen.

One major issue could be with discipline; the operator, culture, and self (aspects of airmanship and CRM), but even with this there is usually some other contributions which all add up to result in an accident. We need to identify a wide range of contributors to gain an understanding and the reasons why they might come together at this point of an approach, and then teach pilots to recognize these and avoid the situation.

[arc-en-ciel]

looking at the FDR graphs, really a shame there is no Ground Speed mini function on Boeing 737 ....

[Tee Emm]

We need to identify a wide range of contributors to gain an understanding and the reasons why they might come together at this point of an approach, and then teach pilots to recognize these and avoid the situation.

Forget the wide range of things to blame from management excesses to the local dog on the runway. And forget the never-ending list of other excuses for crashes. As with so many crashes in that part of the world, it all boils down to one thing - and that is ethnic culture. The "Real men don't go around" culture which includes the centuries old Loss of Face syndrome. Plus the stunned mullet shock of "it can't be happening to me"

The Bali debacle is so very typical. Short final - sudden loss of visibility due blinding rain typical in those areas - keep it going down mate because we'll be through this lot in a couple of seconds ... **** this really is heavy rain.... only a few more seconds and we'll have to go-around - OK going around..SPLASH!... too late

[Capn Bloggs]

I wouldn't be getting wound up by the traces indicating real windshear; deviations of +/-5° and 500ft/min are easily induced and just as easily corrected if the aircraft is bouncing around a little or one is looking in the wrong spot for too long.

The preliminary report says that the EGWPS did not go off. Is this evidence, in your mind, that WS did not happen?

EGPWS has nothing to do with windshear (unless, because of it, a high sink rate develops at low altitude; not here, by the looks of it).

The report said: "The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR." That would be in relation to the EGPWS profile mode where it'll warn you if you're too low, too far out on approach. This aircraft was too close to the normal approach flight path to trigger that warning.

(this is why bloggs tends to splonge in short of the threshold when attempting a visual approach when he shouldn't be)
Splonge?? I'll use that when apologising for my landing! :)

[woodja51]

As much as I would like to be enlightened by this incident, to use it to prevent another occurring, it just doesnt seem to be the case anymore...I frankly cant see justification in putting what appears to be a perfectly good aircraft into the sea.. All those factors that have been mentioned fatigue, culture, beliefs training etc etc... Just start to sound like excuses to me after a while...ALL pilots should arrive at the minima with no preconcieved idea of what to expect.. Unplugging everything in what was obviously ( at some point) marginal conditions is asking for trouble if you dont have to do it... Of course we all make mistakes, and aircraft are very safe but will we as a community learn anything that will prevent the same thing happening again... Probably not as these errors have all been made before ... This is just a variation on the same theme... It may have been safer to leave lnav / vnav in and just let the autopilot fly to the ground most likely would have ended up on the runway with a heavy landing ... But that is just an opinion.. Glad no one hurt but if I read the same thing happened next week somerwhere else, I would not be surprised... It is getting monotonous hearing about ground collisions off NPAs again and again... sorry if I sound hard as*ed about this but I weary of the guys in the front seats doing silly ( if unwittingly!) things...

[framer]

Of course we all make mistakes, and aircraft are very safe but will we as a community learn anything that will prevent the same thing happening again... Probably not as these errors have all been made before .
That depends on whether we shut our minds off to the real causal factors.
All those factors that have been mentioned fatigue, culture, beliefs training etc etc... Just start to sound like excuses to me after a while...ALL pilots should arrive at the minima with no preconcieved idea of what to expect..

That's a great ideal but who is choosing "ALL pilots"? The airline is, and how do they choose them? By determining which ones favour the bottom line. Which ones are willing to pay to fly. And who's job is it to intervene if the standards are too low? The Regulator.
We can bemoan the fact that the crew made errors until the cows come home but that will have no effect on the likelihood of this occurring again next week. What will have an effect is revisiting the decisions made by the airline and the Regulaor regarding recruitment and training.
So it comes down to this, do you want to prevent it happening again or do you want to pour scorn upon others for their mistakes made ?
PS this wee rant isn't directed at you Woodja51. It's just a 'general rant'.

[Boomerang]

So if these guys willingly continued below the minima (not talking 50' here, but CFIT!), as a crew, then lets see an appropriate penalty for negligence, or what could have resulted in manslaughter.

There is NO excuse for this behaviour, and a very clear message needs to be sent to other pilots with a similar attitude that continuing below minimas IMC during normal ops will never be tolerated. Passengers see cheap airfares, but they don't see what they're paying for. Regulators and lawmakers need to step in to even the playing field.

We've all heard anecdotes of this (continued flight below minimas) happening with different results, hence there needs to be a greater deterrent.

Fly to bali with some marijuana and you spent a large part of your life in jail, fly into the ocean with a serviceable 737 (potentially killing all on board) and you get ...

(Sorry for my strong words, but I know the standards the majority of us professional pilots operate to, and to see cowboys like this out there just pizzes me off!)

[Mikehotel152]

A little harsh, I think. If a person crashes a vehicle on a motorway due to reckless driving and causes a 30 vehicle pile up, leading to a heavy loss of life, the person would expect a jail term but nothing like that which would be imposed for mass murder. The difference, of course, is a lack of 'intent'.

I am not excusing their behaviour and poor airmanship. In fact, I agree that there are too many 'cowboys' flying these days (perhaps there always have been) but pilots need to be incentivised to fly to their professional potential. Say a pilot with good potential and a basic licence goes to fly with a cowboy operator or the same pilot instead gets lucky and goes to a legacy carrier. After 3000 hrs his or her day to day performance will be very noticeably different.

Plenty of us will admit to flying 'better' on a line check than on a day out with a long-standing buddy. Professionalism is about gaining and then maintaining standards, but no individual is perfect all the time.

What we have here is a serious case of all the holes in the Swiss cheese lining up and causing an accident. At any time, a single event - a Go Around - would have saved the day. The key point, however, is not to come down hard ONLY on the crew, but to look carefully at all the causal factors in equal measure.

An over-worked PIC? A steep cockpit gradient with an inexperienced SIC (one could argue that hours in a logbook doesn't equate to experience; whereas assertiveness from the SIC improves with experience); the whole P2Fly concept and a lack of experience in the cockpit; a lack of respect for SOPs; rostering and other factors that encourage get-home-itis; an ineffective Regulator.

There is a long list of causal factors, very few of which were touched upon in the preliminary report.

[fireflybob]

To a greater extent I see it as a lack of regulation.

Human beings do the best they can with the resources they have at the time - this includes such items as training and culture whether company wise or other

We need to have two well trained professionals in the flight deck (or more if required) for safe operation.

Am surprised nobody has mentioned the monitored approach system which has been proven to be a safe way of operation. Of course both crew members must be proficient and trained for any system to work every time but having used different systems I am convinced (and statistics seem to back this up) that the monitored approach system is sound.

I know from other threads this can be an emotive topic but for those of you who have never flown monitored approaches I ask you to be a little more open minded. I was very sceptical until I practised same and soon became a convert.

[fox niner]

People, please.

It will never be "culturally acceptable" to fly any serviceable aircraft into the sea.

This accident still looks like criminal negligence and recklessness on behalf of the crew. Sure, there probably were some circumstances which have put the crew into this situation: Bad training. Bad regulatory oversight, etc.
But even then, it is everyone's own bloody responsibility, that when you find out that you have joined an outfit in which things are badly safeguarded for whatever reason: GET OUT. Find another job. Otherwise you will end up getting arrested for having committed criminal negligence and reckless flying.

[FullWings]

Just read the initial report. A full CVR transcript and some N1s would complete the picture but it doesn't look pretty as it is.

Can we learn anything from this accident that we don't know already? Don't bust minima, especially on an offset NPA? I think that one was settled some time in the last millennium.

I'm sure there will be compounding factors of fatigue, poor selection, training, supervision, CRM and oversight. Add in authority gradient, cultural differences/mores and there you have it.

If this was a western airline, the authorities would probably be initiating criminal proceedings against the pilots. I presume the insurance company (assuming they were insured) isn't overjoyed either...

[despegue]

Far too many incidents with Lionair.
Pay to fly Pilots including Captains and voila...
Get this pathetic insult to Aviation safety out of the skies Indonesia, and get your act together!

[Avenger]

‘I can’t see the runway’ is an important cue, but may not have to be a trigger to go-around if the airport environment is in sight.

The whole basis of "modern thinking" is to keep matters simple, stick to minima and SOPs, if, at minima they did not have the required visual ref to continue to land they should have executed a missed approach. They continued to descend below minima for a further 20 secs before the PIC took control and then at 20 feet attempted a go-around.. we know from LV practice that at 20 feet with flap 40 there is a high chance of touch down, of course not if over water! how can we attempt to analyse the "crew thinking" at the time? the tower could see the A/C as could one waiting departure, it would appear the flight crew were somehow completely disoriented and confused and clearly the CRM aspect, or lack of, plays a large part in this. One could understand a " cultural issue" if the PIC was PF and a less assertive FO, but this was not the case and the PIC did not, as PM make the required command decisions at the time. Yes we can learn, but can they?

[sabenaboy]

Am surprised nobody has mentioned the monitored approach system which has been proven to be a safe way of operation

I don't have experience with monitored approaches and therefore I'm not in a position to criticise or praise them, but I don't see how it would have prevented the outcome.

I'm sure that in both systems you simply have to go around if you're not visual by the minima. If the crew elects elect to ignore basic SOP, catastrophe is bound to occur in either system.

[lederhosen]

Quick suggested test for airline managers perhaps for use by the insurance industry. Read the following statements and decide which best reflect your airline's attitude and allocating points as follows:

Strongly agree 1 point, somewhat agree 2 points, unsure 3 points, disagree 4 points, strongly disagree 5 points


We carefully select a variety of pilots, on average with several thousand hours

We train to real proficiency and money on training is money well spent

Pay to fly with the training department as a profit centre is dangerous

Ensuring our pilots are well rested and avoiding roster changes is important

Safety is our priority, there is no punishment for go-arounds or diversions


If you have 10 points or less well done, we will be happy to insure you.
With 10 to 20 points you might like to consider some element of self insurance
Over 20 points we would strongly recommend you stop flying to Greece and other countries which have a history of sentencing airline managers to large fines and jail time.

[gazumped]

It would appear pretty clear as to what happened, I would like to put forward some suggestions as to why it happened and what can be done about it.
Waiting for a third world regulator to take some form of decisive action, could end up just trying your patience.
Having worked for a couple of companies that put pressure on crew to break the rules in order to improve profitability, I feel that I am in some way qualified to comment.
Firstly pilots love to "get the job done", and there is a tendency to feel a failure if you go around and, end up diverting to an alternate. Low quality companies make no attempt to defuse this natural tendency or to indoctrinated pilots into the secrets of professionalism.
The secret of aviation professionalism is OBEY THE BLOODY RULES!
On the other hand good quality companies actively encourage crew to follow all legal and company SOP's.
This is reflected in the accident and incident statistics of good companies versus low quality companies, and Lionair is a classic case in point.
If you are unfortunate to be working for a dodgy operator, apply like mad to all of the good companies, but in the meantime, try to maintain your professional standards. If a critical mass of pilots maintain a professional standard, they can actually slowly change the corporate culture of dodgy operators. And it is the corporate culture of an organisation that ultimately drives the safety standard. Let me say that again, it is the corporate culture that ultimately drives the safety standard. P2F would have to defined as very poor corporate culture.

So bottom line, if your company fails to supply professional direction, supply the professionalism from your own resources. Work hard at knowing the rules, maintain as high a standard as you are able to. If you are an FO, don't be shy to speak up, command a go around if things are getting out of shape, hit the TOGA button and take over if you have to, the very worst that can happen is your employment may be terminated, at least you will be alive and you can hold your head high. If you have a command maintain your standards! The overall goal is to die as an old retired codger with lots of wrinkles, and lots of grey hair.
Lastly keep accurate records. Accurate documentation will be invaluable in defending your position, should that become necessary. Remember All crooks hate being publicly exposed. The power of public opinion can be a powerful lever. Above all else do your best to stay safe. The safety of world aviation is collectively in our all of hands.

[India Four Two]

If you are an FO, don't be shy to speak up, command a go around if things are getting out of shape, hit the TOGA button and take over if you have to

gazumped,
That's very commendable and obvious, but if the FO is from an Asian culture, it may be impossible.

[gazumped]

It is a fact that Asian carriers have a substantially worse safety record than western airlines, and your comment bears testament to that fact.
Do you wish to change that situation? If you do, and for the sake of aviation safety, you should, attempt to change corporate culture one person at a time, (starting with you own mindset), it is the only logical course of action available.

Of course the other course of action is just give up and go with he flow. A personally easier path but not constructive, as far as safety is concerned.

[fireflybob]

I don't have experience with monitored approaches and therefore I'm not in a position to criticise or praise them, but I don't see how it would have prevented the outcome.

I'm sure that in both systems you simply have to go around if you're not visual by the minima. If the crew elects elect to ignore basic SOP, catastrophe is bound to occur in either system.

sabenaboy, on a monitored approach the FO always flies the approach - if on reaching minima the Captain has not taken over control to land (ie after acquiring visual reference) the FO automatically performs a Go Around. (The FO is colloquially known as the "Go Around Man" or maybe that should read (ahem) "Go Around Person" now).

I am sticking my neck out a bit here but would suggest that statistics show that airlines which use the monitored approach concept have far fewer accidents on NPAs.

In the promotion of the Monitored Approach we were advised that a survey of approach accidents over a ten year period found that in circa 75% of cases the approach was a NPA and the Captain was flying the aircraft.

I am not saying this is the sole cause of this accident but venture to suggest that if this crew had been taught and were practised in monitored approaches we would not be discussing this accident now.

[framer]

It's a bit of a Hijack there firefly. There is a whole thread on monitored approaches. I do them and think they are just fine but you are missing the point if you think you can prevent a crash like this by teaching them a different way of flying the approach. For a start that involves the crew displaying discipline at adhering to SOP's and it would surprise me if this crew have followed their SOP's with discipline. In addition the company has allegedly had so many incidents with P2F at the controls that they don't allow the F/O's to be at the controls below 5000ft, yet they persist with the recruitment system. I doubt they are now going to suddenly trust these same pilots to fly all the NPA's.
The solution isn't monitored approaches, the solution is reform at an Organizational and Industrial level.
If it were to occur it would be a slow grind but results could be seen within a couple of years. Unfortunately about the only motivator I can think of to initiate this type of reform would be if enough airlines were banned from operating internationally. That might gee a few of the politicians into making something happen.

[fireflybob]

It's a bit of a Hijack there firefly. There is a whole thread on monitored approaches.

framer, yes I know - I feel suitably chastised!

The solution isn't monitored approaches, the solution is reform at an Organizational and Industrial level.

With the latter concerning Organisational I concur but nevertheless having sound operational techniques would, I suggest, also make a big difference.

[Ted Nugent]

Very very lucky they fell short of that sea wall!

[lomapaseo]

We need corrective actions to prevent the next Lion Air similar accident. Criminal prosecution of these pilots provides nothing more than the satisfaction of extraordinary punishment for poor CRM.

Some of us are looking for a heavier hand to be laid on Lion Air by their regulator to minimize the occurences of crew errors.

I would look to the adequacy of training as well as the failure rate culling process of those who do not display expected CRM abilities under pressure. Standing down a few pilots before an accident might be in the right direction.

I don't know what problems exist with the regulatory body so no comment there as yet. I typically don't look to them as causing an accident other than permitting the situation that contributes to an accident.

[ManaAdaSystem]

From an insurance pilot of view, I would not be surprised if Lion will get the same treatment as Korean.

[Lonewolf_50]

Any comment, and I mean any comment, about runway unsighted @ 150 feet (unless conducting cat11 or cat111) is call for an immediate go around.

Scenario, if one of the crew members makes a statement that he can't see the runway, and the other crew continues, exactly what use to you is the unsighted pilot? He may as well not be on the flight deck.

By continuing descent after that statement the unsighted pilot is rendered
useless to you as a PM. Who in their right mind would willingly render
their PM useless to them?

Two crew is two crew, and as such requires two brains two different points of view, believe me you want your PM to be on the ball actively monitoring,
supporting, challenging you etc. when one crew member states" I can't see the runway" @ 150, that is as big of a red flag you are ever going to get.

If this scenario were in a simulator, and you could flight freeze the
situation, and ask a couple of open questions of each crew member, then they would collectively decide that the only option at 150 feet was a go around.
First off, I extracted that bit from a longer post. Second: good points in re CRM.

Third: "Who in their right mind?"

In order to "get your mind right" you have to buy into the culture that has evolved in the best airlines, where CRM has become a byword and a core competency. Your organization has to embed and nurture that cultural assumption, or it won't sustain over time.

I used to teach CRM, but the truth is that I was a reluctant convert in the 80's as it got emphasized more heavily in my organization. It wasn't until I learned the simple expedient of "hey, Bubba" as my entry level means of breaking the cockpit gradient with some of our more crusty aircraft commanders that I became a believer. Good thing I became a believer. A year later I got a "hey Bubba" froma co-pilot that probably saved us from flying into the sea. I once got a "hey Bubba" from an aircrewman that helped the two of us up front avoid a wheels up landing at an unfamiliar field.

CRM didn't come from Orville and Wilbur. The lessons learned that led to it were written in blood. While I don't disagree that the info to date show us a crew with poor discipline, sending out undisciplined crews is a profound organizational issue, as is "getting pilots' minds right" regarding how team work, CRM, and cockpit gradients (and adhering to SOP) all fit together in professional aviation outfits.

Sorry for the long post. The root causes (at the human factors level) in this one smell of supervisory error, and numerous deficiencies in organizational climate.

[fox niner]

when one crew member states" I can't see the runway" @ 150, that is as big of a red flag you are ever going to get.


Nah... The problem is that they didn't go around at 550 feet which is the MDA.

Neither at 500 feet. (FIVE HUNDRED)
Neither at 450 feet.
Neither at 400 feet.
Neither at 350 feet.
Neither at 300 feet.
250 feet. Nothing.
200 feet. Nothing.
150 feet. "I can't see the runway" the F/O says. Change of controls.
100 feet. nothing happens. (ONE HUNDRED)
50 feet. nothing happens. (FIFTY)
(FOURTY)
(THIRTY)
(TWENTY) the captain initiates a go around.
(TEN) (SOUND OF ENGINE SPOOL-UP)
(SOUND OF IMPACT)

[pilotchute]

Something missing.

PF didn't call go around at MDA and Captain didn't do anything. So the Captain actually wanted to descend lower in the hope of becoming visual. No one "froze" or became disorientated either I presume. The Captain had made the landing decision long before the got to the MDA.

I had Sriwijaya tell the tower the other day that he had me visual when he was actually 5 miles away heading in the other direction to turn inbound for the approach. This is very common here. Why did he say that? Well because he knows that if he says he can see me the tower will clear him for the approach. If he cant see me then he will be made to wait. The Lion Air Captain going in to Bali probably had loads of reasons why he wanted to land first time and they could be anything from needing to meet his girlfriend (going around and into the hold and then shooting another approach may take up to an hour and that's eating into my time he's thinking) to not wanting to have to eat his Nasi Goreng cold. You also have to remember that going around here will cause all sorts of nonsense not only from management but from fellow Captains not letting you hear the end of it. Not landing first time is almost like not being man enough for the job.

The question we need to ask is why had the Captain made the landing decision before he commenced the approach?

[sleeper]

‘I can’t see the runway’ is an important cue, but may not have to be a
trigger to go-around if the airport environment is in sight.


On this VOR approach the terrain and thus environment is water. There are no approachlights. Not seeing the runway is in effect not seeing anything at all.

[ant1]

Posts #767, #856 and #858 summarize the ugly truth about this accident.

[smiling monkey]

I had Sriwijaya tell the tower the other day that he had me visual when he was actually 5 miles away heading in the other direction to turn inbound for the approach.

Makes me wonder what aircraft type you fly, pilotchute? It's usually possible to sight an aircraft 5 miles away on final when you're visual on downwind, in Bali, unless you fly something small like a lighty.

[Oakape]

Perhaps if he was about to turn inbound on the approach, he was 5 miles behind him! Hard to see an aircraft 5 miles behind you at that angle.

[IcePack]

Shame rain repellant (rainbow) is no longer climatically acceptable. Might have saved the day. B*** good stuff. I wonder how many accidents have/will occur due to it's withdrawal. But then monitoring & sense will also work.

[ManaAdaSystem]

The aircraft was nearly new, so the window coating would have been in good condition when they crashed.

[captjns]

Shame rain repellant (rainbow) is no longer climatically acceptable. Might have saved the day. B*** good stuff. I wonder how many accidents have/will occur due to it's withdrawal. But then monitoring & sense will also work

Someone please explain how "RAINBOW RAIN REPELLENT":ugh: would have saved the day, when the crew descended well below the MDA far from the airline. Perhaps had they followed SOPs and gone around when they lost sight of the runway... well you have the proper sight picture.

As a side bar, I use to apply Rain-X to my wind screen on the old 727 way back when. Worked better and lasted a longer time:ok:. Never landed 1/2 mile short of the runway either:D. But I guess that was because of proper adherence to SOPs and situational awareness.

[Capn Bloggs]

+1 for the rain repellant! Brilliant goo. Now I get deafened by wipers that sound like they're going to explode! Just what you need at the MDA, a cacaphony of noise to distract you.

[tbaylx]

You are all missing the point..this is a huge improvement. Most of Lion Air's previous incidents and general destruction of Boeing's finest products have been because of unstabilized approaches. Here they were nicely stable all the way down into the sea.

Now if they can combine that with not continuing when you can't see anything perhaps they can order half as many aircraft next time and not wreck as many.:D

[Fly3]

FYI rain repellant has been changed and is fitted to lots of aircraft although I have no idea if it was on this aircraft. Given the reported severity of the rain reported I doubt if it would have made much difference in this case.

[nitpicker330]

Rain repellant or no rain repellant...........irrelevant really.

PF ( whether the Captain or not ) NOT having the required visual reference at the minima OR losing it after the minima REQUIRES an immediate go around.....

It's not Rocket science.

[ExSp33db1rd]

It's not Rocket science.

QED

Why is this thread still going.

The evidence is out. Pilot error, pure and simple, the reasons are not necessary. Who cares why they had ge-thome-itis

[framer]

Heh heh, that's pretty funny speedbird :)
Unless of course you're serious.

[Centaurus]

Rain repellant or no rain repellant...........irrelevant really

The purpose of rain repellent is give the crew a clearer vision through the windscreen in heavy rain. On countless occasions when approaching to land at Pacific atolls and the visibility is momentarily lost due to a very heavy shower , a quick squirt of rainbow rain repellent immediately caused the rain covering the windows to break up into individual blobs or droplets and it was quite amazing you could see between the blobs and certainly enough to continue visually quite easily. We swore by the stuff.

Later windscreens were coated by a special material which in theory gave better visibility in rain. Experience showed that that coating soon wore away and it became useless.

If inadvertently the rain repellent was squirted on a dry or merely damp windscreen it would form a white residue on the windcreen. The only way to clean it off was with a special very expensive bottle supplied by Boeing I think. An easier way and far less expensive, was to shake a bottle of Coca-Cola then squirt the contents on the windows. That stuff cut right through the residue, quick smart. That is probably why, as many teen-agers later discovered, Coca Cola could eventually rot their guts!

.
Some 737 pilots in SE Asia would sometimes carry in their navigation bag, bottles of commercially available Rainex car window rain repellent, which was quite effective. At $5 a bottle, it was good insurance. Of course it had to wiped on to the windscreen before engine start if the forecast indicated heavy rain at the destination.

In the case of the Bali accident, if rain repellent was installed, then its immediate actuation on entering the area of heavy rain nearing the MDA could have allowed the crew to keep the runway in sight at that critical period rather than letting the aircraft descend in the blind hope of spotting the runway through the rain when there was no hope.

[nitpicker330]

I don't care if the 738 was fitted with rain repellant or not the facts seem to be the CAPTAIN couldn't see the runway through his windshield. ( why we don't know, rain? Cloud? Dirty window? Glasses fogged up!!?? )

Either way he couldn't see, otherwise he wouldn't have flown into the water ( one would hope )

[windytoo]

Ostriches also find it very difficult to see out if they have their head buried in the sand. So was the captain an ostrich? or did he just screw up?

[VH DSJ]

This thread is starting to get ridiculous ... two supposedly professional pilots puts a brand new 89 million dollar airplane into the water on Kuta beach and you're saying a cheap bottle of rain repellant could have saved the day? Have we ran out of things to discuss in this thread? Seems like it. This and the earlier other ridiculous suggestion above that the crew didn't bother to go around because the pilot didn't want to miss out on his nasi goreng is bordering on the insanely ridiculous things I've ever read on pprune.

[ManaAdaSystem]

Some 737 pilots in SE Asia would sometimes carry in their navigation bag, bottles of commercially available Rainex car window rain repellent, which was quite effective. At $5 a bottle, it was good insurance

It is also highly flammable, and classified as dangerous goods.

[pilotchute]

This and the earlier other ridiculous suggestion above that the crew didn't bother to go around because the pilot didn't want to miss out on his nasi goreng is bordering on the insanely ridiculous things I've ever read on pprune.

May be the most ridiculous thing you have read on pprune but as things go in this part of the world that is only mildly silly.

Ask the pilots that run into mountains in IMC flying a published route but not at or above LSALT?

The controller who simply forgot about a large hill and turned a DC 10 into it whilst he was vectoring them to the approach?

The loading crew who thought it was totally acceptable to smoke whilst unloading 44 gallon drums of gasoline from a BAe 146?

I think those are more suited to your "insanely ridiculous things" quote

[ImbracableCrunk]

I've never seen a "Rain-X MDA" on any of my Jepps.

[FlightPathOBN]

Oh great...you know how impressionable regulators are..

Now we are gonna have Rain X minima on the charts. :\

[RetiredF4]

Some 737 pilots in SE Asia would sometimes carry in their navigation bag, bottles of commercially available Rainex car window rain repellent, which was quite effective. At $5 a bottle, it was good insurance. Of course it had to wiped on to the windscreen before engine start if the forecast indicated heavy rain at the destination.


You think, they should be sued for not buying Rainex instead for busting MDA?:ugh:

[gazumped]

The root causes of this accident cannot be simply sheeted home to the crew and the crew alone.
How about 1) Regulator MIA
2) Poor training
3) Corporate culture
4) Chief pilot attitude
5) Peer pressure
6) Company SOP's
There are probably a dozen other systemic latent failures still firmly cemented in place. All of the above reasons are pure guess work on my part, (however backed up by 40 years in the industry seeing it all happen again and again).

I am only guessing that all of the other culprits hiding behind desks will get away absolutely Scott free, and the poor old crew will get it in the neck. Unusually the crew are able to actually talk about what happened, in this instance, normally they would be in the morgue, and be unable to attempt to defend themselves.

The sobering reality is, the buck finally stops @ the flight deck, we, collectively, can stop this happening again by having our own "sensible SOP's".

OBEY THE BLOODY RULES"!!

I am bumping my gums in vein, because somewhere, someone, will do the same thing again. The only excuseable ways of loosing your life in an aircraft are, struck by a meteor, in in flight bomb, an uncontained fire, and a heart attack!! All other reasons are avoidable. The next crew to do something silly because of, peer pressure, lousy corporate culture, poor regulatory oversight, poor training, etc. etc. will probable not be able to talk about it.

[Heathrow Harry]

all they had to do was to go around when they reached MDA

all the other stuff has a bearing but it 's not the reason they wrote the plane off

[Vc10Tail]

Count the number of MONTHS..before the next statistic...if not weather ity is plane trtouble if not plane trouble it is pilot trouble if not pilot trouble it is rergulation trouble and if not that...it is airline growin too quickly trouble..but trouble will always be there..w.be forewarned!

[Up-into-the-air]

Well said gazumped Have a read of the inquiry in Oz about PelAir ditching senate 2011 thread It already has happened

[Lookleft]

The sobering reality is, the buck finally stops @ the flight deck, we,
collectively, can stop this happening again by having our own "sensible SOP's".

Just as relevant to that other water landing! The system is not there to help the pilot.

[gazumped]

You are absolutely correct the Pelair ditching is a black mark on Australia's aviation record. The "system" did its absolute best to make sure that he crew copped ALL of the blame.

It is what public servants do best, when he s&$t hits the fan it is a disaster, however if a public servant can be nailed for it, that is a really really big catastrophe.

The Senate report makes for very interesting reading, actually it is quite sickening as to just how low some public servants can stoop!

[barit1]

pilotchute:The controller who simply forgot about a large hill and turned a DC 10 into it whilst he was vectoring them to the approach?

You're probably referring to a Garuda A300 approaching Medan (http://www.airdisaster.com/cgi-bin/view_details.cgi?date=09261997&reg=PK-GAI&airline=Garuda+Indonesia).

[JammedStab]

Still waiting to see an official accident report on this crash.

Any help is appreciated.

Corrected....on the A300 crash.

[mm43]

The Preliminary Report (http://dephub.go.id/knkt/ntsc_aviation/baru/pre/Preliminary_Report_PK-LKS_Lion_Air.pdf) was released by the NTSC on 14 May 2013.

[Machinbird]

Paragraph 1.12
The initial photographs revealed that the vertical stabilizer, right stabilizer, wings and
control surfaces were in good condition with minimal damage. The right engine and
both main landing gear had detached from the main wreckage.
They will probably want to change the reference to state that the left stabilizer was in good condition (since the right one was sheared off.)

It will be interesting to see if they briefed the approach minimums on the CVR. If they failed to, that would indicate intent to proceed until visual.

[smiling monkey]

Now, this is how you do it boys ...

http://www.facebook.com/photo.php?v=537103489687891

Not hard is it? Quick, decisive decision to go around. None of this BS, handing over to the captain to do the GA as was the case with Lion Air. :rolleyes:

[Starbear]

[QUOTE] Quick, decisive decision to go around /QUOTE]
Really? I heard absolutely no reposnse to the Auto "Minimums" call just continued as if to land but no statement to that effect (or otherwise) There were a few words muttered at "approaching decision height" but the G/A occurred significantly later, I assume due to reduced viz. And thats ok with no fuss and calm methodical execution but hardly the perfect example of "this is how you do it boys"

[smiling monkey]

My point is that in the video they were still visual at the minima and perfectly ok to continue the approach. It was when they lost sight of the runway that they quickly and decisively decided to go around. And this is what the Lion Air crew should have done.

[ExSp33db1rd]

My point is that in the video they were still visual at the minima and perfectly ok to continue the approach...........

Agree......

[david1300]

vtlS0sxFlHk

[RAT 5]

I fly B738 and often on NPA's using VNAVPTH. It's very good and inevitably pops us out of cloud with 2R 2W: assuming the NPA glide path matches the PAPI. I've just read the interim report of this accident. I assume they were also using VNAVPTH and that the glide path would intercept the RWY about the touchdown zone. The TCH is usually elevation + 50' in the LEGS page.
The report stays, as confirmed by CVR, that at MDA (550'-ish) there not visual but continued descending. The captain took over at 150' and a GA was initiated at 20'-ish. At no time did the EGPWS alarm sound as they did not enter the envelope.
This would suggest that they did not stuff the nose down and enter a hi-ROD and so trigger 'sink rate.' They impacted the water 300m from the threshold. This is 600m from the normal touchdown point.
My curiosity is how? If they were on profile at MDA, in trim, on speed etc via the automatics, and they did not trigger 'sink rate' how could they end up so short.
I see they did disconnect the automatics at minimums, and continued the descent manually. There was a slight reduction in attitude and a slight increase in speed; but could this have put them so short? The FD must have been screaming (silently) to raise the nose. Perhaps both pilots were searching outside. Either way, my thoughts about being in trim and thus on a correct glide path still stand. To be so short I'm surprised they did not get 'sink rate'.

Any thoughts?

[KingAir1978]

This would suggest that they did not stuff the nose down and enter a hi-ROD and so trigger 'sink rate.' They impacted the water 300m from the threshold. This is 600m from the normal touchdown point. They DID stuff the nose down. In the FDR readout you can see that the ROD briefly reduced when the automatics were disconnected, but immediately after, the ROD went to app 1100'/min.

Thinking about it, it is actually as form of 'art' they were unable to keep the airplane stable but at the same time, were JUST able to avoid a GPWS alert...

[FR8R H8R]

Any reason the wipers remain on throughout the go-around?

[Capn Bloggs]

Any reason the wipers remain on throughout the go-around?
Probably because the crew had more important things to do at the time...

[RAT 5]

Thinking about it, it is actually as form of 'art' they were unable to keep the airplane stable but at the same time, were JUST able to avoid a GPWS alert...

Which suggests that if they'd not disconnected, or at the very worst followed the FD they might have made land-fall, even the RWY. Mind you, not visual, you should not play those silly games unless the tanks were empty or other highly mitigating circumstances.

[RAT 5]

OK465: You have studied the data more deeply than I and I thank you for the insight.

[FR8R H8R]

What could possibly be more important than turning off the wipers? The boss would be be pissed when he would have to replace them.
God, I love corporate aviation.

[1stspotter]

Final report has been published. You can read it here
http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final%20Report%20PK-LKS%20released.pdf'

Flightglobal reports on the report
Lion Air crew castigated in Bali crash final report - 9/1/2014 - Flight Global (http://www.flightglobal.com/news/articles/lion-air-crew-castigated-in-bali-crash-final-report-403198/)

The final report into the crash of a Lion Air Boeing 737-800 aircraft on short finals to land at Denpasar's Ngurah Rai International airport on 13 April 2013 has identified several safety issues around the skill of the pilots and the carrier's emergency response procedures.

The National Transportation Safety Committee (NTSC) report retains the same chronology as the preliminary report issued in May 2013. As with the earlier report, it highlights the failure of the captain and first officer to communicate effectively prior to impacting the water. The final report also refers to CCTV footage, which shows the extent of the rainy weather immediately prior to the crash, which prevented the flight crew from seeing the runway.
Continue at source

[smiling monkey]

Although the aircraft's automated systems issued a "minimum" warning at 550ft, the crew disengaged the autopilot and autothrottle, and continued the descent flying manually. .....

At 300ft, the report reveals that the cockpit voice recorder picked up a sound consistent with rain hitting the windshield, although there was no sound of windshield wipers. When the 737 had descended to just 150ft, the captain took control of the aircraft, while the first officer again said that he could not see the runway.

During interviews, the captain maintained that he was confident the runway would appear at any moment. It was only when the enhanced ground proximity warning system called a 20ft height alert that the pilot commanded a go-around but, just 1s later, the aircraft impacted the water.



Where do these clowns get their licenses from? :rolleyes: They have absolutely NFI :ugh:

[SOPS]

So can I assume they went below the minima while not visual with the runway?

[henra]

...
During interviews, the captain maintained that he was confident the runway would appear at any Moment....



Ahhh, confidence is a wonderfull criterion when dealing with minima...

[Callsign Kilo]

On reviewing the report, the training records of the two 'pilots' are quite frankly an embarrassment. A completely avoidable accident that wrote off a brand new aircraft and very fortunately didn't kill anyone. Words fail me.

[smiling monkey]

From the CVR transript:

At 0708:56 UTC SIC stated that the runway was not in sight

At 0709:12 UTC PIC stated that approach light in sight and decided to continue the approach

.. only problem with that statement by the PIC is that there are no approach lights to runway 09 at Denpasar WADD. :rolleyes: :ugh:

[vilas]

From the time the PIC took over below the minimums he was only fixated to sighting the RW and landing and when he didn't sight the RW he was just frozen. The report indicates that even at 20ft. with a ROD 1136ft/mt except verbalizing a GA precious little else was done, no change in pitch, no triggering of Go Levers only a mere 3% manual increase of N1. Every airline has SOPs but the actual monitoring of it and the culture prevailing will decide the outcome in crunch situations. If this captain would have pulled off this landing and became an object of admiration instead of censure then it is a matter of time this co-pilot will attempt it and may not be able to pull it off.

[Capn Bloggs]

Interesting that the FO has to go back to the overwings to assist opening during a ditching.

[Gulf News]

There is no doubt that the crew made a complete hash of the final approach with very poor decision making, situational awareness and procedural compliance however one thing I noticed in the report was that the PIC had flown 205 hrs 20 minutes in the preceding 60 days. That is a lot of flying on a predominately short haul operation. This does not seem to have been remarked on by he investigators.

Is this the modern way now and deemed to be totally normal and acceptable in this age of cost cutting and maximum productivity?

[captjns]

One of the worse things that can happen to the civilized world of aviation is if the black ball status is lifted which would allow Lion Air jeopardize safety beyond the borders of their current operations.

[DaveReidUK]

So can I assume they went below the minima while not visual with the runway?Happily, the link to the NTSC's final report provided in post #886 means that we don't need to make any assumptions about what may or may not have happened.

[WingNut60]

Not only can you assume they went below the minima while not visual with the runway, you can assume they went (at least a little bit) below sea level without being visual with the runway.

[tightcircuit]

The visual reference required to go below minima on a NPA under EU ops are as follows;

VISUAL REFERENCE
The pilot shall not continue an approach below minimum
descent height unless at least one of the following
elements is distinctly visible and identifiable to the
pilot:
– elements of the approach light system,
– threshold, threshold markings, threshold lights or
threshold identification lights,
– visual glide slope indicator,
– touchdown zone or touchdown zone markings,
– TDZ,

The requirements in the Lion Air ops manual are similar but I can't cut and paste them. They are in the report if you care to read it. Since the crew had sight of approach lights and runway end indicator lights they would have been fully legal to continue below minima. Having probably justifyably gone below minima the problem they were then faced with was at what stage do you then throw the approach away if the runway does not become visual as expected. The lion Air manual goes on to say that a go-round should be performed if visual reference cannot be maintained but it does not specifly a minmum level of visual reference. It does not specify that the runway must be in sight.

This is not as clear cut as a crew busting minima and anyone who thinks it is really needs to do a bit more study.

[ACMS]

Rubbish-

RWY 09 in WADD does NOT have any approach Lights.

So at the MDA on this non-precision VOR approach they were required to sight the runway or at the very least approach Environment and Threshold. The VIS req for the approach is 2,100m for gods sake.

This Captain didn't see jack and continued, he didn't even turn on the wipers...:D

If he had seen the approach environment such as the 15' high dam wall or threshold HE WOULDN'T HAVE FLOWN INTO THE SEA would he.:D

He said it himself in the report....."I expected to see the runway....." and he admits he never did.

Whatever the rules you don't fly around blind below MDA "feeling" you way to the runway!!!! Especially on a non-precision approach...:mad:

[smiling monkey]

Since the crew had sight of approach lights and runway end indicator lights they would have been fully legal to continue below minima.

I have flown in to WADD over 300 times and about 75% of the time, on runway 09. There are NO approach lights to runway 09.

[despegue]

Tightcircuit,

Stop defending this Insult to Aviation Safety called Lionair that should have its AOC revoked with immediate effect.
Poor Airmanship is rooted in this "airline" that thrives on exploitation of their PAYING First Officers and upgrading/hiring the embarrassingly incompetent as Captain.

Unfortunately, Indonesia, and its passengers do not give a damn about Safety, as long as tickets are cheap.
An extremely worrying trend spreading to the rest of the World.

[smiling monkey]

The lion Air manual goes on to say that a go-round should be performed if visual reference cannot be maintained but it does not specifly a minmum level of visual reference. It does not specify that the runway must be in sight.

Are you for real?? Please don't tell me you're actually a professional pilot. If you can't see the runway, then how the :mad: are you going to land? Well, I tell you how, you won't land on the runway but you'll end up in the water just like PK-LKS did.

If you are infact a pilot for Lion Air and this is how you approach your flying then, you have just convinced me that I, or any of my family members, will never step foot on a Lion Air aircraft for as long as we live.

[SOPS]

I don't believe that some can actually contend that it was safe to go below the minima on that approach when they could not see the runway.....this industry is really falling apart.:ugh:

[chimbu warrior]

The report attributes blame to the crew (quite reasonably), but makes no mention of organisational failings, company culture or policies.

With the Captain having flown 205 hours in 60 days, it is not unreasonable to expect some level of fatigue, particularly when conducting short-haul operations in the tropics.

Lion Air appears to have emerged from this without any change to their operating policies or practices (the Chief Pilot memo is surely a joke). This is not their first hull loss, and in view of the foregoing, is unlikely to be their last.

[Lonewolf_50]

With the Captain having flown 205 hours in 60 days, it is not unreasonable to expect some level of fatigue, particularly when conducting short-haul operations in the tropics.
While this may be true, I don't think you can write off to fatigue a fundamental decision to not do the normal thing: go around at MDA when you do not have the field in sight. There is a bit more than fatigue going into this basic failure to apply procedures to a situation.
Lion Air appears to have emerged from this without any change to their operating policies or practices (the Chief Pilot memo is surely a joke). This is not their first hull loss, and in view of the foregoing, is unlikely to be their last.
I called my bookie in Las Vegas. He was not willing to cover my bet (at any odds) that Lionair will have another accident, and probably soon.
He knows smart money when he see it. Bookies make their money on "dumb money" ... and I wonder at Lionair (Corporate) understanding smart risk assessment versus dumb risk assessment.

Your points on there being a bit more to this than pilot error are reasonably put.

[tightcircuit]

I am amazed by the lack of professionalism shown by folks on here who think they know better than the regulatory authorities about what is and what is not allowed at minima on a non precision approach. If the authorities say that it is OK to go below minima without having the runway in sight then what makes you all believe that it is not. I am not defending Lion Air and I did not say that the Lion air pilots did the right thing. Clearly they didn't or they wouldn't have crashed. I did say that if they had the required visual references at minimums as they claimed (visual references that the authorities specify not me) then they did not bust minima. Try reading the report, reading the section on minima in your ops manual and then re-reading my post.

No I do not work for lion Air. I work for a long established European airline but have had a great deal of experience of flying in Indonesia on Haj contracts over 15 years. I know about the standard of aviation in that country. The point I am making is that saying that going below minima without the runway in sight is against the rules is untrue and is not helpful in understanding the true cause of the accident.

By all means criticize Lion Air but do it for the right reasons otherwise it just devalues the lessons to be learned. Don't let your hatred of that airline distort your judgement.

[donotdespisethesnake]

I am just SLF, but I find that view very worrying. I read the report, and the purpose of the SOPs appears to be clear, even obvious, to a non-pilot.

Is yours a widespread view amongst pilots?

[despegue]

Tightcircuit,

Yes, I read the report.
And luckily, yes, I know my legislation, and as Captain, I luckily realize that COMMON SENSE takes over from anything written in a dubious form or omitted, by the people who have never flown an aircraft ( like you I am certain), and put the safety of my aircraft, crew and passengers first.

The PIC claimed he had the Approach lights in sight. Well, RWY09 in DPS does not have approach light system. The PIC was thus lying during his post accident interview. FACT.
If you see approach lights at minima ( and minimum three by the way so you have a 3 dimensional reference,) it means that visual contact with the runway is imminent. If not...

If at ANY point during any approach below the DA/MDA you lose contact with the touchdown zone of the runway, you GO AROUND immediately. BASIC airmanship AND written in any FCOM.
If these jokers imply that you can land manually without a Vertical precision guidance and without full visual contact with the touchdown zone, you belong FAR away from any type of aircraft, you should probably not even be allowed to ride a bike due to an astonishing lack of Safety consciousness and intelligence.
Since when is an omission or unclarity in a manual a reason to totally forego decisionmaking, safety and airmanship?!:mad:

[tightcircuit]

despegue,

your tone leads me to conclude that you were probably still in nappies when I made my first NDB approach with no automatics in limiting weather conditions. Insults like yours do not add to a discussion in any meaningful way.

The PIC said he saw the approach lights. Maybe he lied. He also said he saw the flashing RWY indicator lights. Maybe he lied. The TWR say they saw the a/c on finals and then gave landing clearance. Maybe they lied too. None of that changes the fact that you do not need to have the RWY in sight to continue below minima. The rules do not say when you have to gain sight of the RWY. That is where the airmanship comes in. I suppose that just going-round anyway when you are in fact allowed to continue a little further dispenses with the need for airmanship that's all. To tell me that you need to see the RWY before you land on it is rather obvious in my opinion. I had managed to work that one out for myself thanks, close to 40 years ago now.

There are several approaches on our network (at least until recently) where the minima are so high that your methods would regularly preclude a landing even in weather approaching VMC. It is not an omission in the rules to allow descent below minima without sight of the rwy. in many places it can be a necessity.

Oh and by the way you do not need three consecutive lights for visual reference on an NPA under EU ops. You do however for cat I, cat II, cat IIIA and IIIB fail passive ILS.

[despegue]

surely you must know that it does not mean that if TWR saw landing lights, the aircraft involved saw the runway or any appropriate references.They are not related and frankly irrelevant, especially in weather involving rainstorms and low clouds.

[tightcircuit]

Yes I know that. It is however corroborating evidence of what the vis was when they were cleared to land.

Look I am not defending what they did after passing minima. It clearly seems that the vis deteriorated and then they should have gone-around as you rightly point out. All I was trying to clarify in my original post is that if they did indeed have the required visual reference at MDA, which they claim they did and the investigation seems to accept, then they were not wrong to continue. IE they did not bust minima. If you do not agree with their decision at that point then fine but if perchance they were not lying then they were not breaking any rules.

Blaming the accident on busting minima stifles consideration of the real mistakes which came slightly later.

[av8r76]

What exactly is the point of having minimums then? Just fly down to airport elevation by cross checking heights with DME or follow the GS all the way down. Why bother with CAT 1, 2, 3 or let's add 4 just for your exemplary skills and insightful interpretation of the regs. And at 20 feet IF you don't have rwy in sight go around. Isn't that what these two guys did? Or shall we go with a self determined minimum which each pilot is comfortable with?

You might like playing chicken with terra firma but I will do it like it is done the world over as mandated by local and internationally mandated norms and regulations....Visual reference by MDA/DA. If not, I get the hell out of there.

I will echo grinning simians point that you really don't belong anywhere close to the pointy end of any airplane. You have in a span of a few posts single handedly destroyed the fundamental requirements of continuing an approach. I seldom contribute to any threads but this bulls#*$t you are spewing needs to be stopped.

[despegue]

IF they indeed had the required references, the crew was correct to continue, I agree on that Tightcircuit. The regulations however do assume that Captains have some intelligence and airmanship and the fact that the actual TDZ must not be visual at DA but the immediate surrounding must, implies that visual contact with TDZ is imminent. If not ....TOGA and Missed approach.
The regulation gives crews some leeway to use in a professional manner, nothing more nothing less and is based on a presumption that a crew is experienced, capable and in the posession of a brain.

[tightcircuit]

Ah at last, We are in agreement then. I agree with your last post entirely.

[tightcircuit]

AV8R76,

Are you talking to me? What do you not understand about the fact that they claim they had the required visual reference at MDA. Let me say it again with emphasis. THEY CLAIM AND THE REPORT SEEMS TO ACCEPT THAT THEY HAD THE REQUIRED VISUAL REFERENCES AT MDA. Of course I am not advocating continuing regardless. What do you do if you have the required references at decision? Are you suggesting you should go-round anyway just in case thing deteriorate? Blimey just read my posts properly please.

[JammedStab]

AV8R76,

Are you talking to me? What do you not understand about the fact that they claim they had the required visual reference at MDA. Let me say it again with emphasis. THEY CLAIM AND THE REPORT SEEMS TO ACCEPT THAT THEY HAD THE REQUIRED VISUAL REFERENCES AT MDA. Of course I am not advocating continuing regardless. What do you do if you have the required references at decision? Are you suggesting you should go-round anyway just in case thing deteriorate? Blimey just read my posts properly please.

Could you tell us what specific required visual references they had. Seeing as there are no approach lights but the crew said they saw approach lights and therefore continued seems to suggest that they didn't have the required visual references. Perhaps if they had looked at the approach chart more closely, they would have noticed this and realized that any lights seen outside are not approach lights.

I have gone around more than once after having the required visual references at minimums. Once for losing sight of the approach lights on a 300 foot DH ILS and more than once in whiteout conditions on non-precision approaches where depth perception was inadequate leading to being high.

I doubt they saw anything useful. You have to know your distance versus height, what rate of descent is required among other variables such as runway length and conditions, etc and put it all together.

If you are going to just plow on down(such as in an emergency), then have a plan and create a stabilized descent rate on a proper glidepath using your technology well back from the MDA. We did that in the old days.

[smiling monkey]

Tightcircuit, Indonesian CASR part 91.175 (c) (3) does require the runway, approach lights or threshold markings to be in sight before descending below the MDA. Since there are no approach lights leading to runway 09 at Denpasar, then the crew would need to at least have the threshold or runway end lights in sight to continue below MDA. To say that you do not need to have the runway in sight in this case is wrong.

If you did have it in sight, of course you could continue the approach. Noone is arguing against that (or else you would never ever land), but, as stated in the Indonesian CASR part 91.175 (e) a missed approach must be conducted at any time you lose sight of the runway when below MDA.

Even if the captain had sight of the runway at MDA, he definitely lost sight of it later on. And I suggest you re-read the report. The FO stated twice that he could not see the runway. It was only the captain who 'claimed' to have the runway in sight which he obviously didn't because the inbound course of the VOR is 091, but the runway track is 087. There is a 4 degree offset which must be corrected for when becoming visual to line up with the runway centreline. The data from the report indicated the aircraft continued on a track of 091 until it hit the water. The captain obviously wasn't visual at the MDA.

[WingNut60]

At 300 ft and 1100 fpm vertical and no runway in sight surely there was something telling the PF that a GA might be a good idea.

Opinions please, at what point would YOU have initiate the go-around.

[Lookleft]

From the report the PIC only stated Go-Around, it wasn't even initiated. No TOGA no pitch change.

[porterhouse]

Opinions please, at what point would YOU have initiate the go-around. Opinions??? For something that is enshrined in regulations and airline procedures?
Someone before showed the approach plate for this approach, there is a Mapt clearly visible on the chart, this is where they should initiate go-around. And by the way it's altitude (MDA) is depicted as 465 ft, you have no business descending even a foot below this altitude if you can't see runway.

[ACMS]

Certain individuals in here defending the Captain need to open their eyes---

1/ there are no approach lights on 09
2/ if there are no approach lights then the Runway threshold and touchdown zone MUST be visible.
3/ you NEVER fly below any decision height without the required visual reference, EVER. We do not blindly sniff around feeling for the runway:D
4/ if you subsequently lose visual reference when below the minima you MUST IMMEDIATELY GO AROUND..... No if's or buts.

He didn't even switch on the wipers!! :sad: he was obviously over loaded.
He admitted to waiting to see the runway, even when below MDA.

He's damn lucky he didn't kill anyone.

Now, Lionair must also accept some of the blame in respect to training, checking and the safety culture in the Airline.

[Lonewolf_50]

I think tightcircuit's point was that "runway environment" suffices, not "the runway itself." I doubt that would be disagreed by anyone who has flown.
A bit of hair splitting, but a fair enough point. Details matter.

The issue regarding "we saw runway lights" that were not there does NOT mean the runway environment was in sight.

It may mean a number of other things ...

[smiling monkey]

I think tightcircuit's point was that "runway environment" suffices, not "the runway itself." I doubt that would be disagreed by anyone who has flown.
A bit of hair splitting, but a fair enough point. Details matter.

The issue regarding "we saw runway lights" that were not there does NOT mean the runway environment was in sight.

It may mean a number of other things ...

The Indonesian CASR Part 91.175 (c) is quite specific about what needs to be seen to allow descent below the MDA;

91.175

(c) Operation below DH or MDA. Where a DH or MDA is applicable, no pilot may operate an aircraft, except a military aircraft of Indonesia, at any airport below the authorized MDA or continue an approach below the authorized DH unless

(1) The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers, and for operations conducted under Part 121 or Part 135 unless that descent rate will allow touchdown to occur within the touchdown zone of the runway of intended landing;

(2) The flight visibility is not less than the visibility prescribed in the standard
instrument approach being used; and

(3) Except for a Category II or Category III approach where any necessary visual reference requirements are specified by the Director, at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:

(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.
(ii) The threshold.
(iii) The threshold markings.
(iv) The threshold lights.
(v) The runway end identifier lights.
(vi) The visual approach slope indicator.
(vii) The touchdown zone or touchdown zone markings.
(viii) The touchdown zone lights.
(ix) The runway or runway markings.
(x) The runway lights.

[olasek]

"runway environment" suffices, Wrong, whether FAR or Indonesian CASR, or European JAR the regulations never mention anything like "runway environment".

[smiling monkey]

The issue regarding "we saw runway lights" that were not there does NOT mean the runway environment was in sight.


"We" ? The FO on two occasions said he could not see the runway. It was only the Captain who 'claimed' to see the the approach lights. And as has been stated many times already in this thread, there are NO approach lights leading to runway 09. So who knows what he saw.

It seems like the Captain was handed the controls by the FO because the FO was convinced the Captain had the runway in sight. And if he did, they wouldn't have ended up in the water. A more assertive FO would probably have conducted the go-around anyway, despite what the Captain saw, as it was the FO who was PF.

[smiling monkey]

At 300 ft and 1100 fpm vertical and no runway in sight surely there was something telling the PF that a GA might be a good idea.

Opinions please, at what point would YOU have initiate the go-around.

Not an opinion, but the regulations say, when you are below the MDA or DH and you lose visual reference with the runway, you must conduct a missed approach.

Indonesian CASR Part 91.175

(e) Missed approach procedures. Each pilot operating an aircraft, except a military aircraft of Indonesia, shall immediately execute an appropriate missed approach procedure when either of the following conditions exist:
(1) Whenever the requirements of Paragraph (c) of this section are not met at either of the following times:

(i) When the aircraft is being operated below MDA; or
(ii) Upon arrival at the missed approach point, including a DH where a DH
is specified and its use is required, and at any time after that until touchdown.


If anyone remembers the Qantas QF1 incident at Bangkok in 1999, this was a similar occurrence where visual reference was lost on short final where the FO who was pilot flying, correctly initiated a go-around, but only to be aborted by the Captain as the wheels touched the runway. The aborted Go-around and subsequent landing resulted in a runway overrun and extensive damage to the aircraft.

[MrSnuggles]

Dear all.

The link to the accident report seems to me to be dead somehow. No matter how many times I try, I get the error "Operation timed out" when following the link provided both here and on Google.

Could someone please point to an alternative location for downloading this report?

It is very interesting to read all your comments and opinions in this matter. Surely the pilots professionality must be questioned, but imho that question must be concerned with the overall safety culture in the entire company - as was the fact with Korean once many moons ago. Loss of face or plain insecurity may be a serious thing, even in Western cockpit culture it seems sometimes (for [only one] reference, the First Air accident in Canada about two years or so ago).

[olasek]

The link to the accident report seems to me to be dead somehow.
It is working for me at this very moment.
But the site is slow, when I first tried it over 24 hrs ago - it failed.
I doubt there are alternate links.

[MrSnuggles]

I was struck by genius and looked it up on ASN and yes, I could download the report there!

Here is the link, if someone has the same problems as I did.

ASN Aircraft accident Boeing 737-8GP (WL) PK-LKS Denpasar-Ngurah Rai Bali International Airport (DPS) (http://aviation-safety.net/database/record.php?id=20130413-0)

Back to my regular lurking dim wits now...

[lilflyboy262...2]

Doesn't surprise me.
It's quite common see that mentality in the captains here.

The other day I was climbing out on the R175, a Lion 737 was opposite direction for landing, descending on R190.
They wanted to go direct to the IAF for the approach which is on R120.
They turned first, across our outbound path, then asked ATC for the clearance which was then denied. So they turned back across our path back to their initial radial.
We watched them on TCAS for the initial crossing, the second crossing we had them visual and was at a point considering taking evasive action.

Then today a Sriwijaya Air 737 managed to overrun the airport at a 2500m runway in moderate rain, 1000' cloud base and nil wind.
Wasn't a bad one, just the nose wheel off the end requiring a tug to push them back on... but that's the standard of the captains here in indonesia.
Weather gets slightly iffy and landings are dangerous.

[Lonewolf_50]

smiling monkey:
Thank you.

olasek:
The runway environment certainly includes those items mentioned by smiling monkey, at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot: but your point is taken, thank you also, in terms of how regs and rules are written.

[arba]

Smilingmonkey, as your own post 91.175 (c) (3) .. "at least ONE of the following visual references for the INTENDED runway is distinctly VISIBLE and IDENTIFIABLE to the pilot"

and runway is just one of them (references).

[arba]

lilflyboy262, where was that 737 over-ran? any link to the news or report ?

[smiling monkey]

Smilingmonkey, as your own post 91.175 (c) (3) .. "at least ONE of the following visual references for the INTENDED runway is distinctly VISIBLE and IDENTIFIABLE to the pilot"

and runway is just one of them (references).

And your point is?

[arba]

oh come on! to go below MDA you don't have to have RUNWAY! the CASR 91.175 (c) (3) says so.

[pilotchute]

Arab,

I see your adopting or have adopted an Indonesian style of airmanship!

[Capn Bloggs]

oh come on! to go below MDA you don't have to have RUNWAY! the CASR 91.175 (c) (3) says so.
True, but which of that list did the crew have when they continued below MDA?

[arba]

wasn't my watch! but to understand "must see the runway" is not correct!

[smiling monkey]

wasn't my watch! but to understand "must see the runway" is not correct!

My point being the captain stated (on the CVR) that he had the approach lights in sight and advised the FO to continue the approach. Runway 09 at Denpasar does not have approach lights. In order to continue, he needed to have those other items listed in 91.175 (C) in sight.

He may have had some other runway identifier visual at the MDA (there wasn't a call at the MDA to say they were visual, but if he later lost visual contact with any of the items listed in 91.175 (C), then any professional pilot should know what to do in that case.

End result is the aircraft ended up in the water. Why did that happen? You tell me.

[Boomerang]

In this case you should have been able to see the rwy. From the chart MaPt is 1.5 NM to 09THR. (=2.7km) Required Vis is 2.8km. So yes, you did need it for this particular runway/approach.

[iceman50]

Arba

A pathetic attempt to split hairs and reduce the blame.

(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.
(ii) The threshold. Part of the runway!
(iii) The threshold markings. Part of the runway!
(iv) The threshold lights. At the start of the runway!
(v) The runway end identifier lights. Part of the runway!
(vi) The visual approach slope indicator. Beside the runway!
(vii) The touchdown zone or touchdown zone markings. Part of the runway!
(viii) The touchdown zone lights. Part of the runway!
(ix) The runway or runway markings. The RUNWAY
(x) The runway lights. Part of the runway!

:ugh::ugh:

[RAT 5]

I can not remember what kind of approach this was, but it was an NPA. I assume the autopilot was in CMD. I assume they were on a stable and correct vertical path during the approach down to 300' ago. If they did nothing then the a/c should have impacted with the runway around 1000' after the threshold. I assume they were using VNAVPTH & LNAV.
However, they landed well short. Why? Ah! The V/S was 1100fpm. There's a clue. So either a pilot disengaged VNAVPTH and engaged V/S or some muppet disconnected the autopilot when not visual and lowered the nose. Which was it? Who was it? The FDR will tell which control column gave input. Both silly things to do. I can't believe this was a manually flown NPA. Surely not.
Does anyone have the answer about what happened at 300' to increase the V/S. Like I said; if they had left well alone they might have pan-caked onto the runway instead of the beach.

[olasek]

Does anyone have the answer about what happened at 300' to increase the V/S.
Do you know that final report was already compiled, it answers this and other questions? The report is fairly compact, easy read, I suggest you grab it. Pilots indeed disconnected autopilot at about 550' and from that point were flying manually. Yes, this was VOR-DME approach flown autopilot-coupled in LNAV/VNAV mode up to point when A/P was disconnected. I don't think you can answer 'why' a pilot pushed the yoke, you can only register that he did.

[porterhouse]

Does anyone have the answer about what happened at 300' to increase the V/S.
The pilot could have been guilty of attempt at scud-running, that could explain desire to get down quickly in hope of getting below some puff of cloud and gain visual contact with the runway. Many GA pilots did this and perished (some survived), it is not often that you find professional pilots doing something like that but it did happen in history of aviation.

[RAT 5]

Thank you guys for the replies. I admit I have not read the report in detail, most only here; I will correct that. One reason for my curiosity is I instruct on the a/c type and am always interested to find out how/why pilots screw up. It makes for educational input into any training.
Question still remains. On an NPA approach, above minimums, not visual why would any sane pilot disconnect the automatics? There should be one pilot looking outside and one inside. Preferably PNF is searching for the visual reference and PF is monitoring the instruments and flight path. If this didn't happen and PF disconnected to go 'scud running' then it brings into question SOP's and airmanship. The latter is already under scrutiny, the former is in writing.
Perhaps I am mistaken and the disconnect came below MDA; even more scary and disturbing.

[olasek]

above minimums, not visual why would any sane pilot disconnect the automatics?
I don't understand, I am instrument rated and disconnecting A/P slightly above MDA is pretty much a standard procedure at least among GA pilots like myself. They disconnected at around 550' so just about 100' above MDA, perfectly normal considering they had to reduce rate of descent and not bust MDA. Obviously nothing like that happened - they clearly decided to plow even lower in hope of breaking through the clouds. Are you instructing on 737?? So tell us how you would fly this approach by the airline pilot standards.

[Capn Bloggs]

Do some research on CDAs, Olasek. :cool:

[ironbutt57]

Poor training+complacency=accident

[Capn Bloggs]

Bloggs (& RAT), do some research
Now why would I need to do that?

[BluSdUp]

Hi All
I just read the final report and this tread after it was issued.
I have read a few reports in my time but this must be a joke, a project in the local flyingclub?
I was under the impresion that there is a certain template and a bit of minnimum facts that a local NTSB has to come up with.?

No proper CVR timeline transkript for eksampel.
No proper conclusion.
No proper recomandation.
Just a lot of repeats ,irrelevant quoats grafs and nice pictures.
They say the Crew lost the big picture, well they lost the Greater picture!

[Skyjob]

OK456 "...the NG VNAV system when the coded E/D is not at an RWXX waypoint and..."

Quotes FCOM:
- An E/D point must be defined in order to accomplish a path descent. It may be defined manually or by the selection of an arrival procedure.
- If a path (VNAV PTH) descent is active when a vertical angle leg becomes active, the path mode will remain active, but VNAV will follow the vertical angle rather than the idle thrust descent path.
- For an approach without a runway waypoint on the RTE LEGS page, the VNAV path is calculated to the MDA or a calculated altitude at the missed approach point. The calculated altitude may be below the MDA to ensure a flight path angle and normal threshold crossing height.

And most importantly this NOTE:
It is the flight crew’s responsibility not to descend below the MDA until adequate visual contact is achieved.

Thus we do not need necessarily a RWXX point, but an angle coded and a E/D point or RWXX point

[Capn Bloggs]

OK465, WTF was all that about?? Unless the 737 has idiosyncrasies, whether there is a RWXX or not is irrelevant (certainly in my "DC9") in this situation. We use approaches with and without RWXX. RWXX is actually a bl@@dy nuisance and in some cases downright dangerous, because it takes you direct from the FAF to the threshold. That is NOT how the approach is supposed to be flown or charted. The approach is designed to cross the centreline on the way to the VOR, with the MDA (or DDA if you like) occurring as the aircraft crosses the CL; a simple turn onto the runway QFU to land. Going via RWXX means I've got to jink towards the CL then back to the QFU to get lined up.

Many of our NPAs don't have 3° displayed in the active plan (ie don't have RWXX) but the machine flies down the charted profile ie 3° (or greater if designed) regardless, as described by Skyjob.

[OK465]

The approach is designed to cross the centreline on the way to the VOR, with the MDA (or DDA if you like) occurring as the aircraft crosses the CL

Bloggs,

I didn't say anything different. The WTF was an explanation that the 737 VNAV will disconnect at the coded E/D at MA09, but the LNAV steering will remain to the VOR. With the runway/REILS in sight, you disconnect everything at MA09, ignore the steering, turn on to final, land and go to the bar.

My point was you can't use LNAV or VNAV inside MA09.

My question remains. What does 717 VNAV steering and auto-flight do at this coded E/D? Or do you know?

(and BTW for this approach it's 2.8 degrees and this will be displayed on the 737 legs page to enable approach geometric from the FAF, but the altitude at MA09 is hard coded and not 'computed')

[Capn Bloggs]

What does 717 VNAV steering and auto-flight do at this coded E/D?
The LNAV follows the Missed Approach coding eg RWXX>VOR>Missed Approach Track, and the VNAV levels off at the inserted MDA/DDA (no "fly-away" logic, unfortunately, unlike IAN). We do not leave it in LNAV and VNAV after the MA waypoint as we are doing the GA then, but after re-engagement of LNAV and VNAV when established in the missed approach, the Autoflight will follow the missed approach including climbing, as per the coded plan.

[Centaurus]

On an NPA approach, above minimums, not visual why would any sane pilot disconnect the automatics

Quite so especially when the final result indicated both pilots lacked basic hand flying skills on instruments. The report indicates the approach was flown on automatics until near MDA when the first officer disengaged everything and continued manually until the captain took over and continued manually into the sea. It proved beyond much doubt what many have long since known. And that is many of todays pilots lack basic instrument flying skills. Automation addiction fostered by company and manufacturers SOP's has much to answer for.

The whole approach could have been easily flown manually and on raw data by any half decently trained pilot. Moreover an instrument rated pilot in a Cessna 172 could fly it. Yet both the pilots lost the plot once the first officer made his own decision to go manually on instruments and within seconds his poor instrument flying ability immediately caused the aircraft to become unstable.

Worse still the captain was driven by the local culture that says that real men don't go around and he too deliberately ducked under. Interesting that he exhibited the same tendency in the simulator judging by comments in his previous training record. 15,000 flying hours in his log book showed he must have got away with unstable approaches for years.

[vilas]

Centaurus
I think you are completely off the mark. In this accident it is not the inability of the crew to hand fly but noncompliance of SOP is the cause. Even the best pilot in the world would have landed in the sea had he continued to 20ft without sighting the runway. Off course he even messed up the GA because except saying go around he did very little else but from 20ft. it wouldn't have mattered, may be would have been worse because he might have crashed into the boundary wall.

[Heathrow Harry]

"Worse still the captain was driven by the local culture that says that real men don't go around and he too deliberately ducked under."

Actually the local culture is not to be confrontational but to work things out together - admittedly a bit tough where they were

[Flying Clog]

@ vilas -

Are you stupid or something?

"Even the best pilot in the world would have landed in the sea had he continued to 20ft without sighting the runway."

Surely if you follow the LOC and GS down to 20 feet, then miss, you won't hit the sea... Surely there's a runway where the LOC and GS meet terra firma no? Or in this case - the magenta LNAV-VNAV guidance down to the RWY point.

At least most airports I've been to that seems to be the case.

If it was poor SOPs but excellent flying skills they would have hit the runway at 1500 feet and slammed on the brakes without seeing a thing! Duhhhhh

(disclaimer - I don't support that sort of landing!)

No, the SOPs are by the by. In fact, I'm sure they were crap too. But the major factor here is useless pilots. You pay peanuts, you get these foolish monkeys. That's a fact for any of these cowboy outfits.

What airline in their right mind would hire pilots from Lionair? I mean, really?

[olasek]

In this accident it is not the inability of the crew to hand fly but noncompliance of SOP is the cause
They both go hand in hand, poor instrument flying skills go with tendency to SOP violations.

[vilas]

Flying Clog
Friend, SOPs are made taking into consideration human and equipment capabilities to ensure consistent results. When you decide to do something stupid there is no SOP for that and obviously the result is as on that day. You are suggesting in heavy rain with zero visibility they should have flown accurately to hit the runway to touch down point. That would have avoided ditching but aircrafts do crash on land and horribly that too. Anybody suggesting what he should have done below minima is very stupid indeed.

[vilas]

olasek
"They both go hand in hand, poor instrument flying skills go with tendency to SOP violations"
There is no connection whatsoever. Following rules is just a matter of mental discipline it has nothing to do with manipulative skills. Haven't you heard that "SOPs are for the guidance of the wise and compliance by idiots" Off course that is a joke but second part applies to this crew.

[lilflyboy262...2]

@Flying Clog

The approach is an offset VOR/DME approach as far as I can remember.

That won't put you on the black stuff.

[olasek]

There is no connection whatsoever This was exactly my point - I claim there is. Sloppiness in pilotage and airmanship carries over to sloppiness in adherence to procedures.

[porterhouse]

No proper conclusion.
No proper recomandation.
Just a lot of repeats ,irrelevant quoats grafs and nice pictures.
Well, there are recommendations at the end but I agree the whole thing is rather brief. An analogous report by NTSB or EASA or AAIB would take 3 times more pages and would have been a lot more detailed.

[India Four Two]

"Worse still the captain was driven by the local culture that says that real men don't go around and he too deliberately ducked under."

Actually the local culture is not to be confrontational but to work things out together - admittedly a bit tough where they were

HH,
I agree but there is also very strong pressure to avoid loss of face. I've often been in meetings where Indonesian professionals will avoid expressing their opinion, in case they are shown to be wrong.

On the aviation front, years ago, I was at Kai Tak and saw a Garuda DC-10 bounce so high, I felt sure it would have to go around. However, it descended and flared again, and disappeared in a cloud of brake smoke at the far end of the runway! A close call.

[Rananim]

Minima bust(or not) is a red herring.This is down to airmanship pure and simple.Autopilot OFF and trouble begins.1150' down at 30' is unforgiveable.They were high and one of the strongest caveats in the recovery process is to re-adjust ROD after recapturing profile.Seems like nobody was able to just "fly the plane".Like Asiana.Like AF 447 and countless others.Pilots are a dying breed being replaced by automation(lionair's answer to its woeful record is not to retrain its pilots to actually fly but rather install smart landing from honeywell) and rote procedure(say this when he does that,you do that when he says this,press this button here after he does that etc...).And to cap it all Lionair is now looking to hire FO's for LHS upgrade.Because they cant get enough experienced guys to fly all the brand new jets theyre getting.Crazy.
Ive retired now but I saw it all unfold in my years in the East as an expat.They dont want the automation out,they want to focus on the button-pressing,the monkey-see-monkey-do rote and the SOP.Btw,a GA after losing visual ref below MDA is simple airmanship(in fact not even that,its basic common sense) not SOP.

[de facto]

Btw,a GA after losing visual ref below MDA is simple airmanship(in fact not even that,its basic common sense) not SOP.

It is in the airline I work for and all the ones prior..,SOP that is.
Not only it is airmanship, but common sense really which could be altered by lack of training.

[framer]

Even the best pilot in the world would have landed in the sea had he continued to 20ft without sighting the runway
What a strange statement. I would guess that about 80% of the guys I fly with ( that's over 100 people) could fly the 737 from the MAP to the threshold using a basic instrument scan of vertical speed , airspeed, and by aligning the noodle with the dashed white line of the runway. Would any of them do it ? No way, they wouldn't even contemplate it. If nothing seen at MDA....."going round flap 15".
But they could if they had to.
Mind you, they all have many hours flying IFR in turbo props and pistons. Maybe that's the difference.
I find it amazing how much variation there is between airlines.

[smiling monkey]

Mind you, they all have many hours flying IFR in turbo props and pistons. Maybe that's the difference.
I find it amazing how much variation there is between airlines.

Lionair has had a P2F program in the past whereby their FO's pay to fly through programs run by EagleJet and MSD. Most pay-to-fly FOs would not have any real commercial experience prior to joining. It's a real pity the paying public are not forewarned of this.

[LowPassGliderA330]

they also offer/offered (?) a transition program me from FO to CPT...

[jetjockey696]

I guess the salary for this capt program is atrocious.. fly 90+hrs of 7000usd..

[jetjockey696]

The salary for this capt program is atrocious.. fly 90+hrs of <6000usd..

they bleeding pilots.. both FO and capt are leaving for better T & C. I got told over 400+ pilots have left. and more to go..up to now. so they been accepting local senior FOs who have been flying CASA (slight bigger than a twin otter etc) to jump straight into B737 as Captain. no jet time or glass time, and relying on the lion cadet pilots/ab initial pilots to stop the bleeding with a non experience jet capt.

All in all there is accident worst than Bali accident waiting to happen.. but i hope not.:ok:

they been using a new agency to recruit captains in europe called presidential something with promise of excellent salary and benefits etc... hahaha...:E

What they are getting are the bottom of the barrel capts with bad or not existence CRM. no one wants.:=

The rainy season is soon to be here... that will sort out the real pilots from the wananbes..

and now the airbus is arriving ....

[mach92]

I spent 3 years in Jakarta flying a Gulfstream around the region. We were not allowed on Lion air at all. I watched them land with tailwinds on wet runways all the time. Take-off in weather we would wait for. Land long and almost go off the end of the runway. Bali did not surprise me one bit.

I had drinks many times with the low time F/O's in a few expat bars in Jakarta. The stories they told were just down right scary. Now reading this thread it seems it will only get worse. Indonesia is not the place for people without good experience.

[ATC Watcher]

Do not disagree with your analyses, but if I read the report right , here , like in many others accidents recently, it is not the" inexperienced FO" , P2F or not, who caused the accident but rather the "old experienced Captain" .
Just a reminder.

[ManaAdaSystem]

So where was the FO?
None of my FOs would allow me to pull a stunt like this.

[B737900er]

The FO was there, but unfortunately his culture is very yes sir, you are totally right sir, to someone who is more senior than him.

The only way LNI will get out of this rut is to have expat management running the show for a few years, and beat safety into everyone.

[framer]

Or you could get expat pilots who have already had safety beaten into them, probably easier.

[Heathrow Harry]

but at a price.................

[framer]

Yip. Indo is a nice place to live though if you can get out of Jakarta.
I imagine 12k USD net for Captains with $200 an hour after 65 hours would do the trick. Much cheaper than putting aircraft into the drink.

[Big Pistons Forever]

I have heard reports that both Capt and FO have been fired. Is this true ?