LION AIR ACCIDENT ON 13 APR 2013 - PRELIMINARY REPORT

(Relevant excerpts of the preliminary report accessed from the Indonesian authority website)

History of the Flight

On 13 April 2013, a Boeing 737-800 aircraft registered PK-LKS was being operated by PT. Lion Mentari Airlines (Lion Air) on a scheduled passenger flight as LNI 904. The aircraft departed from Husein Sastranegara International Airport (WICC) Bandung1 at 0545 UTC2. The aircraft flew at FL 390, while the Second in Command (SIC) was the Pilot Flying (PF) and the Pilot in Command (PIC) was the Pilot Monitoring (PM).

There were two pilots and 5 flight attendants with 101 passengers on board consisted of 95 adults, 5 children and 1 infant. The flight from the departure until start of approach was uneventful.

At 0648 UTC, the pilot made first communications with Bali Approach controller (Bali Director) when the aircraft position was 80 Nm from BLI4 VOR. The pilot received clearance direct to TALOT waypoint and descent to 17,000 ft.

At 0652 UTC, the Bali Director issued a further clearance for the pilot direct to KUTA waypoint and descent to 8,000 ft.

At 0659 UTC, the aircraft was vectored for VOR DME approach for runway 09 and descent to 3,000’.

At 0703 UTC, while the aircraft over KUTA waypoint, the Bali Director transferred the aircraft to Bali Control Tower (Ngurah Tower).

At 0704 UTC, the pilot contacted Ngurah Tower controller and informed that the aircraft position was leaving KUTA waypoint. The Ngurah Tower controller instructed the pilot to continue approach and to reduce the aircraft speed to provide sufficient separation distance with another aircraft.

At 0707 UTC, the Ngurah Tower issued take off clearance for departure aircraft on runway 09.

At 0708 UTC, with the aircraft at approximately 1,600 ft AGL, 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.

The excerpts of the CVR and FDR data on the final approach are as follows:

At 0708:56 UTC, while the aircraft altitude was approximately 900 ft AGL the SIC stated that the runway was not in sight.

At 0709:33 UTC, after Enhance Ground Proximity Warning System (EGPWS) called out “MINIMUM” at aircraft altitude approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle then continued to descend.

At 0709:53 UTC, while the aircraft altitude approximately 150 ft AGL the PIC took over the control.

The SIC handed the control to the PIC and stated that he could not see the runway.

At 0710:01 UTC, after the EGPWS warning “TWENTY”, the PIC commanded a go around.

At 0710:02 UTC, the aircraft impacted the water.

The OCA(H) as per the landing chart for VOR/ DME R/W 09 is 465’ (454’).