Interesting initial review of Lion Air Bali 738 crash sequence
Thread Starter
Join Date: Jan 2008
Location: Europe
Posts: 1,482
Likes: 0
Received 0 Likes
on
0 Posts
Interesting initial review of Lion Air Bali 738 crash sequence
Just found this update from Flight International. For the record, the Indonesian Captain had 15,000 hours and the Indian FO had 1,200 hours with 900 on type (he was flying the approach). See the description below:
Lion 737 crash crew had no visual contact with runway
By: Greg Waldron Singapore
2 hours ago
Source:
Indonesian investigators indicate that the crew of a Lion Air Boeing 737-800 continued to descend below minimum altitude despite not having visual contact with the runway during a non-precision approach to Bali. The National Transportation Safety Committee, in its preliminary report into the 13 April accident, says the first officer, who was flying, mentioned that the runway was not in sight as the aircraft descended through 900ft. Although the aircraft's automated systems issued a "minimum" warning at 550ft the crew disengaged the autopilot and autothrottle, and continued the descent.
Within a minute the 737 had descended to just 150ft and the captain took control of the aircraft, while the first officer again said that he could not see the runway.
The enhanced ground-proximity warning system called a 20ft height alert and the pilot commanded a go-around but, just 1s later, the aircraft impacted the water.
Approach charts show the missed-approach point is 2nm west of the Bali VOR, giving the altitude as 465ft.
While the 737 was severely damaged as it struck, short of runway 09, all seven crew and 101 passengers survived, although four passengers were seriously injured.
NTSC says the 48-year old Indonesian pilot had logged 15,000h in total, with 7,000h on type, but the 24-year old Indian co-pilot had 1,200h and 923h on type.
Surveillance camera images indicate it was raining at the time of the ill-fated aircraft's approach. Indonesian investigators have sought additional information from other pilots about weather conditions at the time. A pilot holding short of runway 09 corroborates that it was raining, with visibility reduced to 1-2km, and he was unable to see the 737 when his collision-avoidance system informed that the flight was 3nm away. Another crew, approaching the airport 5nm behind the Lion Air jet, stated that they could not see the runway at the published minima and decided to execute a go-around.
Flight JT904 from Bandung appeared to be uneventful until the final seconds. The NTSC's timeline of the accident reads as follows:
06:48UTC: While 80nm from Bali VOR, the pilot makes first contact with the Bali controller. The flight is cleared for descent to 17,000ft.
06:52: The pilot is cleared to descend to 8,000ft and proceed to the Kuta waypoint, which lies west of runway 09 over the sea.
06:59: The aircraft is vectored for a VOR/DME approach for runway 09, and cleared to descend to 3,000ft.
07:04: Pilot tells Bali tower that he is leaving Kuta waypoint. The tower tells the crew to reduce speed to ensure sufficient separation with another aircraft.
07:08: Bali tower sees the Lion 737 on final and gives clearance to land, informing the pilot of a 5kt wind from the south-east.
07:08:56: At a height of 900ft, the first officer says he is unable to see the runway.
07:09:33: The enhanced ground proximity warning system calls "minimum" at 550ft. The pilot disengages the autopilot and autothrottle and continues to descend.
07:09:53: Captain takes control at 150ft, first officer says he cannot see the runway.
07:10:01: Ground-proximity system calls "twenty" and captain orders a go-around, but aircraft hits the water short of the runway. The 737 comes to rest 20m from shore and 300m southwest of the beginning of runway 09.
Lion 737 crash crew had no visual contact with runway
By: Greg Waldron Singapore
2 hours ago
Source:
Indonesian investigators indicate that the crew of a Lion Air Boeing 737-800 continued to descend below minimum altitude despite not having visual contact with the runway during a non-precision approach to Bali. The National Transportation Safety Committee, in its preliminary report into the 13 April accident, says the first officer, who was flying, mentioned that the runway was not in sight as the aircraft descended through 900ft. Although the aircraft's automated systems issued a "minimum" warning at 550ft the crew disengaged the autopilot and autothrottle, and continued the descent.
Within a minute the 737 had descended to just 150ft and the captain took control of the aircraft, while the first officer again said that he could not see the runway.
The enhanced ground-proximity warning system called a 20ft height alert and the pilot commanded a go-around but, just 1s later, the aircraft impacted the water.
Approach charts show the missed-approach point is 2nm west of the Bali VOR, giving the altitude as 465ft.
While the 737 was severely damaged as it struck, short of runway 09, all seven crew and 101 passengers survived, although four passengers were seriously injured.
NTSC says the 48-year old Indonesian pilot had logged 15,000h in total, with 7,000h on type, but the 24-year old Indian co-pilot had 1,200h and 923h on type.
Surveillance camera images indicate it was raining at the time of the ill-fated aircraft's approach. Indonesian investigators have sought additional information from other pilots about weather conditions at the time. A pilot holding short of runway 09 corroborates that it was raining, with visibility reduced to 1-2km, and he was unable to see the 737 when his collision-avoidance system informed that the flight was 3nm away. Another crew, approaching the airport 5nm behind the Lion Air jet, stated that they could not see the runway at the published minima and decided to execute a go-around.
Flight JT904 from Bandung appeared to be uneventful until the final seconds. The NTSC's timeline of the accident reads as follows:
06:48UTC: While 80nm from Bali VOR, the pilot makes first contact with the Bali controller. The flight is cleared for descent to 17,000ft.
06:52: The pilot is cleared to descend to 8,000ft and proceed to the Kuta waypoint, which lies west of runway 09 over the sea.
06:59: The aircraft is vectored for a VOR/DME approach for runway 09, and cleared to descend to 3,000ft.
07:04: Pilot tells Bali tower that he is leaving Kuta waypoint. The tower tells the crew to reduce speed to ensure sufficient separation with another aircraft.
07:08: Bali tower sees the Lion 737 on final and gives clearance to land, informing the pilot of a 5kt wind from the south-east.
07:08:56: At a height of 900ft, the first officer says he is unable to see the runway.
07:09:33: The enhanced ground proximity warning system calls "minimum" at 550ft. The pilot disengages the autopilot and autothrottle and continues to descend.
07:09:53: Captain takes control at 150ft, first officer says he cannot see the runway.
07:10:01: Ground-proximity system calls "twenty" and captain orders a go-around, but aircraft hits the water short of the runway. The 737 comes to rest 20m from shore and 300m southwest of the beginning of runway 09.
Last edited by Iver; 15th May 2013 at 14:26.
Join Date: Mar 2013
Location: England
Age: 35
Posts: 58
Likes: 0
Received 0 Likes
on
0 Posts
Join Date: Jan 2006
Location: In a far better place
Posts: 2,480
Likes: 0
Received 0 Likes
on
0 Posts
What's so interesting about a crew which exercise poor judgement and skills and flare a perfectly good jet into the water?
Personally, I think the whole incident is gut wrenching
.
Personally, I think the whole incident is gut wrenching
.
Last edited by captjns; 15th May 2013 at 20:16.
Join Date: May 2001
Location: HERE AND THERE
Posts: 863
Likes: 0
Received 0 Likes
on
0 Posts
Luck
Damm lucky SOBs!
Why on earth some bastards like that decided to violate such basic principles!?
Hope their licenses be revoked forever.
This wasn't an accident: was a criminal act.
Why on earth some bastards like that decided to violate such basic principles!?
Hope their licenses be revoked forever.
This wasn't an accident: was a criminal act.
Join Date: Aug 2002
Location: SE Asia
Age: 39
Posts: 137
Likes: 0
Received 0 Likes
on
0 Posts
How can the F/O just sit there and monitor/watch the Capt fly it into the water ?
Obviously the flight deck gradient/power distance or whatever you want to call it was pretty steep, plus cultural/crm issues etc but we are talking about basic survival instincts and 100 + lives at stake.
Scary !
Obviously the flight deck gradient/power distance or whatever you want to call it was pretty steep, plus cultural/crm issues etc but we are talking about basic survival instincts and 100 + lives at stake.
Scary !
Join Date: Jan 2006
Location: In a far better place
Posts: 2,480
Likes: 0
Received 0 Likes
on
0 Posts
It ain't cultural. Air India Express into Mangalore in 2010. Non-assertive,
American 1420 into Little Rock, Arkansas. Non-assertive F/O, along for the ride to the end flown by a "Gotta complete the mission oriented" bone head.
United Airlines 173 into Portland, Oregon December 28, 1973. Non-assertive F/O and F/E as well as a jump seater too! Gear extension issue, ran out of gas with their thumbs up their arses
American 1420 into Little Rock, Arkansas. Non-assertive F/O, along for the ride to the end flown by a "Gotta complete the mission oriented" bone head.
United Airlines 173 into Portland, Oregon December 28, 1973. Non-assertive F/O and F/E as well as a jump seater too! Gear extension issue, ran out of gas with their thumbs up their arses
Last edited by captjns; 15th May 2013 at 22:21.
Join Date: Jan 2006
Location: In a far better place
Posts: 2,480
Likes: 0
Received 0 Likes
on
0 Posts
Thanks for the reminders of those events,Air india Express got another one coming up ?
Just a comment on most of the posts here so far. They border on an abusive chat room in tone. At the risk of being labelled an old fart who should leave the air safety and accident analysis to ones better qualified, a reminder is not out of place that this is a pro pilot website with rules and standards. Unless a post is pertinent, informed and adds to the debate it is better to shut up and leave it to those really in the know, or at the very least able to speculate with some credence.
When that brand new Legacy over Brazil en route the US took a wing off that Gol B737 in the cruise, head to head, it was a year or two before the in depth, highly informed analysis came out. If you want to read up on this , get this brilliant book , "Inside the Sky", and read the final chapter -
There are numerous similar examples that those seeking an education in air accident investigation might well study closely.
When that brand new Legacy over Brazil en route the US took a wing off that Gol B737 in the cruise, head to head, it was a year or two before the in depth, highly informed analysis came out. If you want to read up on this , get this brilliant book , "Inside the Sky", and read the final chapter -
William Langewiesche's life has been deeply intertwined with the idea and act of flying. Fifty years ago his father, a test pilot, wrote Stick and Rudder, a text still considered by many to be the bible of aerial navigation. Langewiesche himself learned to fly while still a child. Now he shares his pilot's-eye view of flight with those of us who take flight for granted--exploring the inner world of a sky that remains as exotic and revealing as the most foreign destination.
Langewiesche tells us how flight happens--what the pilot sees, thinks, and feels. His description is not merely about speed and conquest. It takes the form of a deliberate climb, leading at low altitude first over a new view of a home, and then higher, into the solitude of the cockpit, through violent storms and ocean nights, and on to unexpected places in the mind.
In Langewiesche's hands it becomes clear, at the close of this first century of flight, how profoundly our vision has been altered by our liberation from the ground. And we understand how, when we look around, we may find ourselves reflected in the grace and turbulence of a human sky.
Langewiesche tells us how flight happens--what the pilot sees, thinks, and feels. His description is not merely about speed and conquest. It takes the form of a deliberate climb, leading at low altitude first over a new view of a home, and then higher, into the solitude of the cockpit, through violent storms and ocean nights, and on to unexpected places in the mind.
In Langewiesche's hands it becomes clear, at the close of this first century of flight, how profoundly our vision has been altered by our liberation from the ground. And we understand how, when we look around, we may find ourselves reflected in the grace and turbulence of a human sky.
Last edited by Fantome; 16th May 2013 at 09:06.
Join Date: Jul 2006
Location: In the Sun
Posts: 53
Likes: 0
Received 0 Likes
on
0 Posts
In the latest findings they say training is the problem, I disagree to the max, Airlines and Lion give the pleasure of Sims every 6 months where we do 3-4 go-arounds due to no visual cues at Da, easy we go around,
The Capt and Fo have had a number of Sims and performed as required.
So where does the problem lay?
The 60 million dollar question?
We all wait with baited breath so see Why How and Who
Crm maybe?
Fatigue?
Power Distance problem?
An easy solution by pushing that toga switch at DA would have solved everything, why the Capt never asked for it or took control and done it, we will never know, or will the company.
The Capt and Fo have had a number of Sims and performed as required.
So where does the problem lay?
The 60 million dollar question?
We all wait with baited breath so see Why How and Who
Crm maybe?
Fatigue?
Power Distance problem?
An easy solution by pushing that toga switch at DA would have solved everything, why the Capt never asked for it or took control and done it, we will never know, or will the company.
An easy solution by pushing that toga switch at DA would have solved everything, why the Capt never asked for it or took control and done it, we will never know, or will the company.
It's not why they didn't perform the GA earlier that's in question. It's why the hell did the PF hand over the controls to the captain 8 seconds before impacting the water that's in question, when he should have instinctively gone round.
Join Date: Oct 2008
Location: Between V1 and V2
Posts: 47
Likes: 0
Received 0 Likes
on
0 Posts
It sounds to me as a double pilot incapacitation case. Co-pilot was frozen at one point and unable to react. Captain took some time to figure out what is going on,he was a bit confused in the beginning,finally he reacted but it was too late.
Join Date: Dec 2006
Location: Aloft
Posts: 40
Likes: 0
Received 0 Likes
on
0 Posts
I guess the investigation is continuing?
Question raised by others: Was RWY visual at MDA (or even MDA+50ft? or were they attempting MDA as DA which is controversial to many!)? It would appear that it may not have been at 550 when the EGPWS went off, and during the precious few seconds between 550ft and MDA (465ft), while the PF was disengaging AP and autothrottle and peering through the rain presumably still looking for the RWY, the aircraft also appears to have started a 1200fps descent.
Definitely points to company training, respect for MDA and use of VDP on NPAs (if, how, etc) and especially human factors.
In fact, apart from what else they might have hit had they actually managed to perform an aborted landing from below MDA (even 150ft less pilot reaction time), the quantum of the MDA is not really so relevant in this case. It's the fact that go-around wasn't performed at or above MDA given specific conditions and late change in visibility, and the apparent lack of command (over all flight instruments and aircraft attitude, descent rate, etc), monitoring and general CRM during that last critical phase below 550ft.
I wonder how much pressure there is to perform despite all odds (eg, WX, VIS) and actually land the aircraft and deliver pax?
Awaiting the final report with interest.
Question raised by others: Was RWY visual at MDA (or even MDA+50ft? or were they attempting MDA as DA which is controversial to many!)? It would appear that it may not have been at 550 when the EGPWS went off, and during the precious few seconds between 550ft and MDA (465ft), while the PF was disengaging AP and autothrottle and peering through the rain presumably still looking for the RWY, the aircraft also appears to have started a 1200fps descent.
Definitely points to company training, respect for MDA and use of VDP on NPAs (if, how, etc) and especially human factors.
In fact, apart from what else they might have hit had they actually managed to perform an aborted landing from below MDA (even 150ft less pilot reaction time), the quantum of the MDA is not really so relevant in this case. It's the fact that go-around wasn't performed at or above MDA given specific conditions and late change in visibility, and the apparent lack of command (over all flight instruments and aircraft attitude, descent rate, etc), monitoring and general CRM during that last critical phase below 550ft.
I wonder how much pressure there is to perform despite all odds (eg, WX, VIS) and actually land the aircraft and deliver pax?
Awaiting the final report with interest.
Last edited by roulette; 21st May 2013 at 13:33.
