Lion Air PK-LKS Accident Investigation Report April 2013

PK-LKS 747-800

Accident investigators examine PK-LKS. Note the Lion Air logo has been painted over.

From a recent article on the April PK-LKS 737-800 April accident in Bali:

“The committee’s report issued safety recommendations to the airline in order to ensure pilots were trained to follow correct procedure in handing over flight controls during critical moments and times. It also called on the airline to “review the policy and procedures regarding the risk associated with changeover of control at critical altitudes or critical times.”

The altitude at which the co-pilot handed control of the plane to his colleague was below the minimum altitude considered safe to continue final descent.”

DPS VOR/DME Runway 09

Looking at the approach plate above in the investigation report (above) … minimum descent altitude (MDA) for a straight-in approach (aligned within 30° of the runway) is 465′ (see red arrow) for the missed approach, yet they descended to 150′ in rain, the copilot handed flying control over to the pilot, who started their missed approach at 20′.

For non-pilots, let me spell this out: the pilot just had to put E on his compass, descend to 465′, and land if the airport was visible, otherwise climb.

A new 737-800 was destroyed, 4 people were hurt, and everybody on board risked their lives because these “pilots” couldn’t follow one of the simplest approach plates.

The training and recency of the SIC is also questionable (Indian, 1200 hours total time, but only 14 hours 36 minutes logged in the past 60 days.)

The following questions come to mind:

  • Why so few recent hours?
  • Was this flight really a training exercise for the copilot?
  • Did he have an earned pilot license, or was it an “Indian expedited license”?
  • Did both pilots have approach plates?
  • If so, why couldn’t they read and follow the approach plates?
  • Does the copilot understand the difference between a non-precision and a precision approach?
  • If so, why would the copilot descend below MDA 465′ to 150′, which sounds like a precision (ILS) altitude?
  • Does Lion Air management pressure pilots to not execute missed approaches to save money, fuel and embarrassment (as in India)?

I advise people flying in Indonesia to completely avoid Surabaya because of the frequent torrential rains, and to check for rain at other airports before embarking on a flight, if possible.

Pilot training blamed for Bali airliner crash
Indonesia NTSC 2013
wikipedia: Instrument Flying

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