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With Boeing in Cross Hairs, Lion Air Gets a Pass on Poor Safety Record
A focus on Boeing after two fatal crashes has given cover to an Indonesian air carrier with global ambitions — a company that will neither fully admit to, nor swiftly address, its safety issues.

By Hannah Beech and Muktita Suhartono
Nov. 24, 2019, 3:21 a.m. ET

When things go wrong, those in power often promise to make it right. But do they? In this series, The Times investigates to see if those promises were kept.

JAKARTA, Indonesia — When Lion Air Flight 610 took off in clear skies a year ago, the 737 jetliner carried with it an anti-stall system designed by Boeing that would propel the plane into a nose-dive minutes after takeoff, killing all 189 aboard.

But the plane was saddled with another safety burden. Flight 610 was operated by Lion Air, a low-cost Indonesian carrier that has benefited from its political connections to become one of the world’s fastest growing airlines, despite a questionable safety record.

While Boeing has faced intense scrutiny after two fatal crashes in less than five months, Lion Air has escaped similar attention, despite obvious failings that contributed to the disaster of Flight 610.

An investigation by The New York Times, based on interviews with dozens of officials and airline employees, including pilots and members of maintenance teams, found that Lion Air has a track record of working its pilots to the point of exhaustion, faking pilot training certification and forcing pilots to fly planes they worried were unsafe, including the plane that crashed.

Despite making vague promises of improvements after last year’s accident, the air carrier has neither fully acknowledged nor expeditiously addressed the concerns that have been raised about its safety practices, both by government investigators and whistle-blowers interviewed by The Times.

“The Boeing issue was an absolute godsend for Lion Air,” said John Goglia, a former member of the United States National Transportation Safety Board and an aviation safety expert. “It means Lion Air doesn’t have to deal with what is clearly failure after failure after failure and make the changes needed.”

Of the nine factors that caused the crash, according to the final report issued by the Indonesian National Transportation Safety Committee last month, a fatal Boeing design flaw in an automated system was what captured the world’s attention, especially after the crash of another plane in Ethiopia linked to its anti-stall system.

Although the report documented lapses on Lion Air’s part, like shoddy maintenance and undertrained pilots, examples of Lion Air’s culpability were underplayed when the report was presented, dismaying critics who note that Indonesia, the world’s fourth-most populous country, struggles with endemic corruption.

“You get the sense that the raw data that makes Lion look bad is buried in the report for whatever political reasons,” Mr. Goglia said.

Lion Air has not accepted responsibility for the failures listed in the report, and it dismissed most of the safety issues raised to The Times by current and former employees.

In a response attached to the final report, the airline wrote that it was “aware of efforts that have been made to criticize the Lion Air pilots, engineers and maintenance personnel who operated or worked” on the aircraft.

The carrier said “such criticisms are misplaced and should not be considered as contributing factors of the Flight JT610 accident.”

Despite the life-or-death urgency of some of the government report’s safety recommendations, including making improvements to Lion’s hazard-reporting process and its safety training, the company seems to be mulling its next steps, rather than taking immediate, decisive action.

“Give me time,” Daniel Putut, Lion Air’s managing director, said in an interview, when asked how quickly the carrier could implement the recommendations. “Let’s say another one or three months because we need to study it to learn if there are things we need to change.”

“The report,” he added by way of explaining the delay, “is 323 pages long.”

While denying that the deficiencies cited in the report played a part in the crash, Mr. Putut said that Lion Air has “tried to improve” how it identifies safety hazards since the disaster.

“The accident hurt us so we have done a deep study of our operational safety to prevent something from occurring again,” he said.

At the same time, however, Mr. Putut defended Lion Air’s business culture, which critics say prioritizes growth over safety.

A former Lion Air chief pilot, Jimmy Kalebos, said that refusing to acknowledge problems was symptomatic of the company’s approach to safety before the crash. That it continues to do so after so many deaths, he added, does not bode well.

“How can you fix a problem,” Mr. Kalebos asked, “if you don’t admit it exists?”

WHAT WE FOUND
‘Absolutely Not Improved’

In the view of some of the company’s most important employees — its pilots — Lion Air has not taken steps to fix numerous flaws since the crash.

The safety culture at Lion Air has “absolutely not improved,” a pilot said. Like other current and former Lion Air staff members, he agreed to speak only on condition of anonymity to protect his career.

Not a single Lion Air employee has been fired as a result of last year’s accident, according to both government investigators and current and former employees. Mr. Putut refused to confirm or deny if anyone had been let go.

Just as the company does not seem pressed to adopt changes from the report (which is actually 322 pages long), Indonesian officials were quick to defend a carrier that has had 11 accidents and incidents since its founding in 1999, according to the Aviation Safety Network.

In comparison, Spirit Airlines, the American low-cost carrier founded in 1980, has suffered two in its history, one in 2002, the other in 2005. Neither was fatal.

What’s more, many additional serious safety lapses at Lion Air were never investigated by the government because the carrier downplayed them or failed to divulge their likely causes, pilots and maintenance workers at the airline said.

In one case in 2016, a Lion Air jet suffered a total loss of engine oil, forcing the pilot to shut down the engine in flight, according to former employees. Yet the Indonesian National Transportation Safety Committee was never called in to investigate.

“What we see in the news is only the visible part of the iceberg,” one pilot said.

But members of the Indonesian government seemed sanguine about the airline’s safety.

“Lion Air maintenance is good,” said Luhut Pandjaitan, a government minister whose portfolio includes oversight of Indonesia’s transportation network. “Lion pilots have no problem. Lion Air facilities are very good.”

He said much of the criticism was fueled by “Western arrogance.”

But Ahmadji Sumankidjo, one of the minister’s own deputies, said there was an unwritten government preference for civil servants to avoid flying Lion Air.

“You can fly Lion Air,” he said, “but you need to pray to God.”

WHAT WE FOUND
‘I Want to Stop, but I Can’t’

Few airline businesses grew as quickly as Lion Air Group, which oversees several carriers in addition to Lion Air. In 1999, Rusdi Kirana started a low-cost carrier with a few rickety jets. By the time of the crash, Lion Air Group had signed deals for 450 brand-new planes from Boeing and Airbus.

On many routes within Indonesia, whose sprawling archipelago makes air travel an everyday necessity, Lion Air was often the only choice, making its peremptory motto oddly appropriate: “We make people fly.”

The Indonesian government has hailed Mr. Kirana as a visionary whose company employed 30,000 people. A Christian in a Muslim majority country, Mr. Kirana took on a leadership position in an Islamic political party with ties to the government and was named ambassador to Malaysia.

As Lion Air grew, all those new planes needed captains, and the company soon suffered from a dangerous shortage of pilots, according to those who watched the company transform.

In 2016, for example, Lion Air had about 3.5 flight crews (a chief pilot and first officer) for each plane in its fleet, according to company insiders, while the industry norm for airlines operating similar kinds of routes with similar planes is at least twice that.

“Do the math,” said Mr. Kalebos, the former Lion Air pilot. “It just doesn’t add up to safety being No. 1.”

While that ratio has since improved, according to current and former employees, the conditions for pilots remain onerous.

Under Indonesian law, pilots are not allowed to fly more than 110 hours a month. But faked logs of flying hours were rampant at the company, according to former and current pilots.

Eki Adriansjah, a former chief pilot at Lion who also served as a flight instructor, said he once worked 300 hours in a month and was chided by government regulators.

“I told them, ‘Why are you catching me and not the company?’” he said. “Lion was the one pushing me to work like that.”

Airline representatives denied its pilots were overworked.

The carrier also hired pilots with contracts that tied them to the carrier for up to 20 years unless they paid a hefty release fee.

“We are all tired,” said a current Lion Air pilot bound by such a restrictive contract. “I want to stop but I can’t.”

On Nov. 18, a co-pilot for Wings Air, another airline within the Lion Air Group, committed suicide after receiving a termination letter from the carrier telling him he owed $500,000 in penalties for the training he had received. In a statement after his death, Wings Air said it had taken employment actions against an “undisciplined” employee.

Some Lion Air pilots say the workload has improved since last year’s crash, with a computerized system, strengthened after the catastrophe, making it harder to cheat on flying hours.

“This was a problem at Lion, but now not so much,” said Koko Indra Perdana, a Lion Air chief pilot and secretary general of the Indonesian Pilots Professional Association.

Others are skeptical.

“I talk to my friends, and they say it’s the same now, they’re just more careful about hiding it,” Mr. Kalebos said.

WHAT WE FOUND
Fly, No Matter What

Current and former pilots at Lion Air recounted dozens of instances, both before and after the crash, in which they felt pressured to fly, despite concerns about the weather, the plane’s airworthiness or even their own alertness.

In two cases, pilots said they were ordered to fly to airports near where forest fires were raging and smoke obscured visibility.

“The manager told me, ‘Oh, you don’t need to see the runway because we have instruments that can see for you,’” said Mr. Eki, the former Lion pilot.

In another case, a Lion Air maintenance crew signed off on a plane as good to go. But the pilot wasn’t confident the plane was fit to fly, and he refused to take off.

Frustrated, a member of the maintenance team contacted a top executive at Lion Air. The pilot soon took to the skies.

Lion Air also had trouble giving its pilots the training necessary to pass a safety audit by the International Air Transport Association, which helps formulate global aviation standards.

Allowing the pilots time for training was hard because the understaffed airline needed them in the air, not in classrooms.

When it became clear that Lion Air would not be able to meet its training targets, a new solution was found, multiple people with the airline at the time said: faking documentation that training had been conducted.

“Fake certificates and a fake attendance list,” said one pilot who was party to the deception. “Now, magically, the S.M.S. training is compliant on paper,” the pilot added, referring to safety management system training. Lion received its I.A.T.A. safety certification in 2016.

Mr. Putut, the carrier’s managing director, said he was not aware of any falsified paperwork. “I’ve never heard about it, these fake certificates,” he said. “I need to check on that.”

WHAT WE FOUND
‘An Accident Waiting to Happen’

The Indonesian report on the crash notes how the plane experienced problems with speed and altitude readings for several days before the Oct. 29 crash.

On the morning of Oct. 28, a different flight crew aboard the doomed plane was told to fly it to the island of Bali because an engineer said a fix would be more easily found there.

Friends of the pilot said he was uncomfortable with the decision, given that on the previous leg, the plane had given him highly irregular data readings. But he flew there anyway on the plane that would crash the next day. The pilot did not respond to queries for comment.

“In any other country, making a pilot fly an unsafe plane like that is illegal,” said Mr. Goglia, the former National Transportation Safety Board member. “I don’t have words to describe how bad it is.”

At the Bali airport, a vane, known as an angle of attack sensor, was replaced.

Crash investigators were presented with photographs supposedly showing that a mandatory test was done after the vane had been replaced. But upon further inspection, investigators concluded the photos were from a different aircraft.

“This is a test that Lion Air was required to do, and they didn’t,” said John Cox, an aviation safety consultant.

If the test had been done, engineers likely would have realized the vane was calibrated incorrectly by 21 degrees. The misalignment would prove fatal because it mistakenly catalyzed Boeing’s anti-stall system, forcing the plane into its final plummet.

No government action has been taken related to the doctored photographs.

Questionable decisions continued after the plane took off from Bali on its next-to-last flight. While in the air, the faulty sensor and the automated anti-stall system kept compelling the plane’s nose down.

But once on the ground in Jakarta late on Oct. 28, the flight crew failed to document the full extent of the problems in the plane’s log, 31 pages of which were missing when it was presented to investigators, a breach for which Lion Air was never chided.

As the plane took off on its final flight, the crew of Flight 610 had no idea of all the troubles faced by the pilots a few hours earlier.

“That plane was unairworthy for days,” Mr. Goglia said. “It continued to be unairworthy because Lion Air didn’t take proper corrective action. It was an accident waiting to happen, and it happened.”

WHAT WE FOUND
Cozy Ties, Conflicts of Interest

In Indonesia, there are close ties between airlines and regulators, which industry experts believe have muted criticism and influenced investigations.

Last year, Nurcahyo Utomo, a lead investigator for the National Transportation Safety Committee, repeatedly said at a news conference that the crashed plane was “unairworthy” on its second-to-last flight.

Lion complained. The next morning, the government agency released a statement saying that Mr. Nurcahyo had “NEVER said” what he had, in fact, said.

Government employees in the aviation sector need to fly to keep their pilot licenses. To do so, they fly for and get paid by airlines like Lion Air. This money can outstrip their government paychecks.

The flow of staff from airline to government — and back again — occurs in management ranks, too.

The lead investigator of Lion Air’s first fatal accident, in which 25 people died in 2004 after a pilot overshot the runway, was Ertata Lananggalih. Four years after releasing a report that critics said underplayed Lion Air’s culpability in the crash, he joined the company, working his way up to managing director. He left Lion Air in 2012 and returned to government work as a senior air safety investigator.

“Indonesia is a corrupt country, but the corruption at Lion is the biggest of all,” said Wicaksono Budiarto, a former pilot for the airline who joined 17 others, including Mr. Eki and Mr. Kalebos, in a lawsuit against the company for dismissing them after they refused to fly in what they considered unsafe flying conditions.

The pilots won significant damages, but Lion Air has refused to pay.

“Nothing’s going to change,” Mr. Wicaksono said. “Lion has too much power.”

The Takeaway: After a crash, a company — and a government — deny problems, deflect blame and drag their feet on improvements.

Hannah Beech has been the Southeast Asia bureau chief since 2017, based in Bangkok. Before joining The Times, she reported for Time magazine for 20 years from bases in Shanghai, Beijing, Bangkok and Hong Kong. @hkbeech
Muktita Suhartono reports for The New York Times in Indonesia and Thailand. She joined The Times in 2018 and is based in Bangkok.
A version of this article appears in print on Nov. 24, 2019, Section A, Page 1 of the New York edition with the headline: Lapses Plague Lion Air, Year After Disaster.

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That experience taught me just enough to recognize something odd about MCAS: It is way too slow to be suppressing aerodynamic instability in a jet aircraft. Whereas the X-29 controller had a response time of 25 milliseconds, MCAS takes 10 seconds to move the 737 stabilizer through a 2.5-degree adjustment. At that pace, it cannot possibly keep up with forces that tend to flip the nose upward in a positive feedback loop.
There’s a simple explanation. MCAS is not meant to control an unstable aircraft. It is meant to restrain the aircraft from entering the regime where it becomes unstable. This is the same strategy used by other mechanisms of stall prevention—intervening before the angle of attack reaches the critical point. However, if Brady is correct about the instability of the 737 MAX, the task is more urgent for MCAS. Instability implies a steep and slippery slope. MCAS is a guard rail that bounces you back onto the road when you’re about to drive over the cliff.
Which brings up the question of Boeing’s announced plan to fix the MCAS problem. Reportedly, the revised system will not keep reactivating itself so persistently, and it will automatically disengage if it detects a large difference between the two AoA sensors. These changes should prevent a recurrence of the recent crashes. But do they provide adequate protection against the kind of mishap that MCAS was designed to prevent in the first place? With MCAS shut down, either manually or automatically, there’s nothing to stop an unwary or misguided pilot from wandering into the corner of the flight envelope where the MAX becomes unstable.

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He is a senior writer and regular columnist for the magazine American Scientist, and was editor in chief for the magazine from 1990 to 1992. He has also edited and written columns for Scientific American, as well as writing for Computer Language and The Sciences.

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