Investigators: Lion Air Pilots Ignored Standard Procedures

 - May 20, 2013, 2:37 PM

Indonesia’s National Transportation Safety Committee’s preliminary report on the April 13 Lion Air accident in Bali appears to leave little doubt that pilot error was the primary cause, specifically a failure by the crew to follow standard instrument approach procedures.

The Boeing 737 crashed just short of Runway 9 at Ngurah Rai International Airport (WADD) and broke into pieces at the completion of a non-precision instrument approach. All aboard escaped the aircraft with just minor injuries, with the exception of four passengers who received serious injuries.

Official weather reports called ceiling and visibility good, but local pilots reported rainshowers moving through the area as the Boeing approached. There were also no maintenance issues with the nearly new 737.

The relatively inexperienced first officer (1,200 hours total) was the flying pilot, being monitored by the captain (15,000 hours total).

According to the NTSC report, approximately two-and-a-half minutes before impact, and with the aircraft at approximately 1,600 feet agl, the Ngurah tower controller saw the 737 on final and gave a landing clearance with the wind 120 degrees at 5 knots. Approximately one minute before impact and with the aircraft descending through 900 feet, the first officer said he did not see the airport. Thirty seconds before the crash, the enhanced ground proximity warning system called “minimums” with the aircraft at 550 feet agl.

With still no runway in sight, the first officer disengaged the autopilot and continued the approach. Nine seconds before impact with the aircraft 150 feet above the water, the captain took control and continued yet another 10 seconds before commanding a go-around. One second later, the Boeing struck the water.