Narrative:
A Boeing 737-800 passenger plane, registered PK-LKS, suffered an accident at Bali's Denpasar-Ngurah Rai Bali International Airport (DPS) in Indonesia. There were 101 passengers and seven crew members on board. All aboard survived.
Flight JT-904 departed originated at Palu Airport (PLW), Indonesia and was bound for Denpasar (DPS), Indonesia with en route stops at Balikpapan Airport (BPN), Banjarmasin Airport (BDJ) and Bandung Airport (BDO).
The flight departed Bandung at 13:45 with the copilot as Pilot Flying. About 15:00 the flight was descending towards Bali and the crew received vectors for a VOR DME approach for runway 09. At 15:08, with the aircraft at approximately 1,600 ft AGL, the Tower controller saw the aircraft on finals and gave a landing clearance with additional information that the wind condition was 120° at 5 kts.
While descending through 900 feet the copilot stated that the runway was not in sight. Since the captain noted a flashing light at the beginning of the runway, he responded: "OK. Approach light in sight, continue". At 15:09:33, after the EGPWS called out "Minimum" at an altitude of approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle and continued the descent. The airplane then entered an area of rainfall and the outside environment became totally dark.
At 150 ft AGL the captain took over control. The copilot handed the control to the captain and stated that he could not see the runway. At 15:10:01, the EGPWS called out "Twenty", and the captain commanded a go around. One second later the aircraft impacted the water.
The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south west of the beginning runway 09.
Contributing Factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
WADD 130700Z 09006KT 9999 BKN017 30/26 Q1007 NOSIG
07:30 UTC / 15:30 local time:
WADD 130730Z 15006KT 110V270 9999 FEW017CB SCT017 30/25 Q1007 NOSIG
Wind 150°, varying between 110 and 270° at 6 knots; unlimited visibility; few Cumulonimbus clouds at 1700 feet AGL; scattered clouds at 1700 feet AGL; Temperature: 30°C; Dewpoint: 25°C; Pressure: 1007 mb08:00 UTC / 16:00 local time:
WADD 130800Z 10009KT 9999 FEW017CB SCT017 30/26 Q1007 NOSIG
accident date: 13-04-2013
type: Boeing 737-8GP (WL)
registration: PK-LKS
| Status: | Accident investigation report completed and information captured |
| Date: | Saturday 13 April 2013 |
| Time: | 15:10 |
| Type: |  Boeing 737-8GP (WL) |
| Operator: | Lion Air |
| Registration: | PK-LKS |
| MSN: | 38728/4350 |
| First flight: | 2013-02-05 (2 months) |
| Total airframe hrs: | 142 |
| Cycles: | 104 |
| Engines: | 2 CFMI CFM56-7B24E |
| Crew: | Fatalities: 0 / Occupants: 7 |
| Passengers: | Fatalities: 0 / Occupants: 101 |
| Total: | Fatalities: 0 / Occupants: 108 |
| Aircraft damage: | Substantial |
| Aircraft fate: | Written off (damaged beyond repair) |
| Location: | Denpasar-Ngurah Rai Bali International Airport (DPS) ( Indonesia)
|
| Phase: | Approach (APR) |
| Nature: | Domestic Scheduled Passenger |
| Departure airport: | Bandung Airport (BDO/WICC), Indonesia |
| Denpasar-Ngurah Rai Bali International Airport (DPS/WADD), Indonesia | |
| Flightnumber: | 904 |
A Boeing 737-800 passenger plane, registered PK-LKS, suffered an accident at Bali's Denpasar-Ngurah Rai Bali International Airport (DPS) in Indonesia. There were 101 passengers and seven crew members on board. All aboard survived.
Flight JT-904 departed originated at Palu Airport (PLW), Indonesia and was bound for Denpasar (DPS), Indonesia with en route stops at Balikpapan Airport (BPN), Banjarmasin Airport (BDJ) and Bandung Airport (BDO).
The flight departed Bandung at 13:45 with the copilot as Pilot Flying. About 15:00 the flight was descending towards Bali and the crew received vectors for a VOR DME approach for runway 09. At 15:08, with the aircraft at approximately 1,600 ft AGL, the Tower controller saw the aircraft on finals and gave a landing clearance with additional information that the wind condition was 120° at 5 kts.
While descending through 900 feet the copilot stated that the runway was not in sight. Since the captain noted a flashing light at the beginning of the runway, he responded: "OK. Approach light in sight, continue". At 15:09:33, after the EGPWS called out "Minimum" at an altitude of approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle and continued the descent. The airplane then entered an area of rainfall and the outside environment became totally dark.
At 150 ft AGL the captain took over control. The copilot handed the control to the captain and stated that he could not see the runway. At 15:10:01, the EGPWS called out "Twenty", and the captain commanded a go around. One second later the aircraft impacted the water.
The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south west of the beginning runway 09.
Probable Cause:
Contributing Factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
Accident investigation:
 |
|
Classification:
Undershoot/overshoot
Sources:
» SKYbrary METAR Weather report:
07:00 UTC / 15:00 local time:WADD 130700Z 09006KT 9999 BKN017 30/26 Q1007 NOSIG
07:30 UTC / 15:30 local time:
WADD 130730Z 15006KT 110V270 9999 FEW017CB SCT017 30/25 Q1007 NOSIG
Wind 150°, varying between 110 and 270° at 6 knots; unlimited visibility; few Cumulonimbus clouds at 1700 feet AGL; scattered clouds at 1700 feet AGL; Temperature: 30°C; Dewpoint: 25°C; Pressure: 1007 mb08:00 UTC / 16:00 local time:
WADD 130800Z 10009KT 9999 FEW017CB SCT017 30/26 Q1007 NOSIG
Follow-up / safety actions
NTSC issued 14 Safety Recommendations
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Photos
accident date: 13-04-2013
type: Boeing 737-8GP (WL)
registration: PK-LKS
Video, social media
Un aereo della compagnia #LionAir è uscito di pista durante un atterraggio a #Bali, finendo in mare: 22 i feriti twitter.com/AltriMondiGazz
— Altri Mondi Gazzetta (@AltriMondiGazza) April 13, 2013
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Bandung Airport to Denpasar-Ngurah Rai Bali International Airport as the crow flies is 857 km (536 miles).
Accident location: Exact; deduced from official accident report.
Distance from Bandung Airport to Denpasar-Ngurah Rai Bali International Airport as the crow flies is 857 km (536 miles).
Accident location: Exact; deduced from official accident report.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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