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Indonesian NTSC Cites Pilot Error In Lion Air Accident

Boeing 737 Missed Its Approach And Wound Up In The Ocean In Bali

The Indonesian National Transportation Safety Committee (NTSC) says in a preliminary report that pilot error is a factor in an accident which resulted in a nearly-new airplane winding up in the ocean near Bali International Airport April 13.

According to the report, "The Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM). The flight from the departure until the start of approach was uneventful.

"The aircraft followed the VOR DME runway 09 instrument approach procedure. The weather while the aircraft was on final was raining. During the approach the SIC mentioned that the runway was not in sight twice. At 0708 UTC, when the aircraft was at approximately 1,300 ft, the Ngurah Tower controller saw the aircraft on final and gave a landing clearance with additional information that the wind condition was 120° / 05 kts.

"At 0710 UTC, the aircraft impacted to the water. The aircraft came to a stop facing north about 20 meters from the shore or approximately 300 meters south west of the runway 09 threshold. A pilot of an aircraft which was awaiting take-off and held short on runway 09 informed the Ngurah Tower controller that the Lion Air aircraft had crashed into the sea near the beginning of runway 09. The Ngurah Tower controller looked at the position as informed and saw the Lion Air aircraft tail section outside the airport fence.

"At 0711 UTC, the Ngurah Tower controller pressed the crash bell and then communicated to the Airport Rescue and Fire Fighting (ARFF) via direct line about the accident. At 0713 UTC the rescue team departed from the ARFF station. At 0715 UTC, the ARFF arrived on the accident site and conducted rescue operations. At 0755 UTC, all occupants were completely evacuated, the injured passengers were taken to the nearest hospitals and uninjured occupants to the airport crisis center.

"Four passengers suffered serious injury and the others were minor or no injury. The aircraft was substantially damaged and submerged into shallow water."

According to the report, the 24-year-old co-pilot had a total of 1,200 hours in his logbook, with 923 in type. Data from the CVR indicates that the co-pilot gave control of the airplane back to the flight's captain at about 150 feet of altitude just before the plane impacted the water. The captain had given a "Go Around" command as the ground proximity alarm indicated that the airplane was just 20 feet off the ground.

The 737 had come off the Boeing assembly line February 19, 2013. It had accumulated only 142 hours and 37 minutes of flying time before the accident.

(Image from NTSC report)

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