B738, vicinity Denpasar Bali Indonesia, 2013

B738, vicinity Denpasar Bali Indonesia, 2013

Summary

On 13 April 2013, a Lion Air Boeing 737-800 flew a day non precision approach to runway 09 at Bali (Denpasar) and continued when the required visual reference was lost below MDA. Despite continued absence of visual reference, the approach was continued until the EGPWS annunciation 'TWENTY', when the aircraft commander called a go around. Almost immediately, the aircraft hit the sea surface to the right of the undershoot area and broke up. All 108 occupants were rescued with only four sustaining serious injury. The Investigation attributed the accident entirely to the actions and inactions of the two pilots.

Description

On 13 April 2013, a Boeing 737-800 (PK-LKS) being operated by Indonesian carrier Lion Air on a scheduled domestic passenger flight from Bandung to Denpasar, Bali as LNI 904 crashed into the sea just short of runway 09 at destination after making a non precision approach and continuing it into Instrument Meteorological Conditions (IMC) below MDA. The aircraft wreckage remained in shallow water near the shoreline and there was no fire and all 108 occupants were rescued with only four sustaining serious injury.

Evacuation from the aircraft after the accident (Reproduced from the Official Report)

Investigation

An Investigation was carried out by the Indonesian KNKT (NTSC). The aircraft SSFDR and SSCVR were recovered and successfully downloaded. Analysis of this data allowed the Investigation to confirm that "there were no issues with the aircraft and (that) all systems were operating normally" and the focus then turned to the pilots.

It was established that the aircraft commander was a 48 year old Indonesian with 15,000 hours experience who had been qualified on the 737NG since 2007. The 24 year old Indian First Officer had 1,200 hours flying experience, the majority on the aircraft type. Both pilots were familiar with operations into Bali.

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