This incident clearly shows that both pilots conspired to intentionally fly the a/c below the published minima for the approach in IMC thus risking the lives of themselves, the passengers and the safety of the a/c. Miraculously no one was killed after the a/c impacted the water and broke up short of the runway. The captain was a very experienced pilot and this in itself most likely contributed to his decision to disregard standard operating procedures and ‘have a go’. There is a very old saying in aviation:
IF THERE IS ANY DOUBT, THERE IS NO DOUBT, GO AROUND
It applies if you are flying a Boeing 737 on a non precision approach at Bali or flying a Cessna 152 on first solo at Halfpenny Green, There is no substitute for experience but as this incident and many many similar ones show, one of the most important requisites on a flight deck, or in a cockpit, is good personal attitude to standard operating procedures and rule based behavior coupled with sound aviation decision making skills.
From the official accident report:
On 13 April 2013, a Boeing 737-800 being operated by Indonesian carrier Lion Air on a scheduled domestic passenger flight from Bandung to Denpasar, Bali impacted the sea and was destroyed short of the intended landing runway 09 at Bali after making a non precision approach. The aircraft broke up on impact in shallow water near the shoreline but there was no fire and all 108 occupants survived with only 4 sustaining serious injury.
An Investigation was begun by the Indonesian NTSC and has gathered factual information and documented initial findings. The aircraft was estimated to have come to rest facing north about 20 metres from the shore in a position approximately 300 metres southwest of the threshold of runway 09. It was concluded that all damage to the aircraft was “consistent with post accident impact with the sea floor, coral reef and sea wall”.
The CVR and FDR were recovered from the wreckage and successfully downloaded. It was demonstrated from this data that the aircraft final approach had not penetrated any EGPWS Alert criteria and that the standard radio height call outs from the same equipment had functioned normally throughout. In all significant respects, the aircraft was found to have been airworthy. The VOR and DME navigation aids being used by the accident aircraft for the approach were also confirmed as serviceable as was the PAPI and runway lighting.
The aircraft commander, an Indonesian national, was found to have substantial aircraft type flying experience and to have been twice the age of the foreign national Co Pilot, who had been designated PF for the accident flight and for whom experience gained on the accident aircraft type with Lion Air in the two years since joining the airline constituted most of his flying experience.
It was established that although the surface wind had remained light, there had been a transient deterioration in the visibility during the last few miles of the final approach due to rain and low cloud. The TWR controller reported having had visual contact with the approaching aircraft when issuing landing clearance as it passed approximately 1600 feet but the aircraft did not subsequently remain visible. A report from the pilot of an aircraft that made an approach 5 NM behind the accident aircraft stated that they could not see the runway at the published minima and decided to go around. Continue reading