Status: | Accident investigation report completed and information captured |
Date: | Tuesday 2 November 2010 |
Time: | 11:18 |
Type: |  Boeing 737-4Y0 |
Operator: | Lion Air |
Registration: | PK-LIQ |
MSN: | 24911/2033 |
First flight: | 1991-04-08 (19 years 7 months) |
Total airframe hrs: | 49107 |
Cycles: | 28889 |
Engines: | 2 CFMI CFM56-3C1 |
Crew: | Fatalities: 0 / Occupants: 6 |
Passengers: | Fatalities: 0 / Occupants: 169 |
Total: | Fatalities: 0 / Occupants: 175 |
Aircraft damage: | Substantial |
Aircraft fate: | Written off (damaged beyond repair) |
Location: | Pontianak-Supadio Airport (PNK) ( Indonesia)
|
Phase: | Landing (LDG) |
Nature: | Domestic Scheduled Passenger |
Departure airport: | Jakarta-Soekarno-Hatta International Airport (CGK/WIII), Indonesia |
Destination airport: | Pontianak-Supadio Airport (PNK/WIOO), Indonesia |
Flightnumber: | 712 |
Narrative:The Boeing 737-400 aircraft, registered PK-LIQ, was being operated by Lion Air on a passenger schedule flight with flight number JT712. This flight was the first flight for the crew and was scheduled for departure at 09.30 LT.
The aircraft pushed back at 09.50 LT. During taxi out to the runway, the yaw damper light illuminated. The pilot checked to the Quick Reference Handbook (QRH) and switched off and back to on. The yaw damper light extinguished. The yaw damper light then illuminated for the second time. The pilot asked the engineer to come to cockpit to observe the problem.
The aircraft departed Soekarno Hatta Airport, Jakarta at 10.12 LT for Supadio Airport, Pontianak. Pilot in Command was the pilot flying (PF) and the copilot was the pilot monitoring (PM). The flight to Pontianak was reported normal.
Prior to descend, the pilot flying gave an approach briefing. There was an additional briefing item that the pilot had experiences that in this specific aircraft sometimes thrust reverser hard to operate and speed brake fails to auto deploy. The PF asked the PM to check the speed brake auto deployment after landing.
The aircraft was instructed to make an ILS approach to runway 15. The weather was reported slight rain. During initial approach the pilot used auto pilot and initial configuration was set with flaps 5 and speed 180 knots. After captured the localiser at 1300 feet, the PF asked for landing gear, down flaps 15 and speed reduced to 160 knots. He aimed to set the flaps landing configuration as the glide slope captured.
When the glide slope was captured, the auto pilot was failed to follow the glide and still maintain at 1300 feet. While the aircraft was on one dot above the glide slope, the PF switched off the auto pilot and auto throttle, to fly manually to capture the glide slope.
The PF then asked for flaps 40 and landing checklist. As the flaps lever has been selected to 40, the flaps indicator indicated to 30 positions. The PF asked for landing speed in case the flaps could be moved further than 30. After completing the landing checklist, PM then reselected the flaps. At approximately 600 feet, flaps 40 were successfully selected.
The aircraft touched down past the touchdown point. After touch down, the PF tried to select the thrust reverser, but it felt that the thrust reverser was hard to operate and the speed brake did not auto-deploy. No deceleration was felt by the crew. The PF then applied manual brakes, and selected speed brakes to be deployed manually. The reversers then deployed. During the landing roll, a loud bang was heard by
passengers, the flight attendants and some other people in the airport.
The aircraft ran out of runway and stopped at approximately 70 meters from the runway or 10 meters past the end of stop-way. The PIC then commanded for passenger evacuation to the flight attendants. All passengers were evacuated through all available exits.
No one injured in this accident. The aircraft has major damage to its engines, the nose landing gear and belly area. There was no other damage reported.
Probable Cause:
Contributing Factors:
- Inconsistency to the Aircraft Maintenance Manual (AMM) for the rectifications performed during the period of the reversers and auto speed brake deployment problem was might probably result of the unsolved symptom problems.
- The decision to land during the un-stabilized approach which occurred from 1000 feet to 50 feet above threshold influenced by lack of crew ability in assessing to accurately perceive what was going on in the flight deck and outside the airplane.
- The effect of delayed of the speed brake and thrust reverser deployment effected to the aircraft deceleration which required landing distance greater than the available landing distance.
Accident investigation:
|
Investigating agency: | NTSC Indonesia  |
Status: | Investigation completed |
Duration: | 5 years and 11 months | Accident number: | KNKT.10.11.17.04 | Download report: | Final report
|
|
Classification:
Landing after unstabilized approach
Runway excursion (overrun)
METAR Weather report:
04:00 UTC / 11:00 local time:
WIOO 020400Z 26004KT 6000 RA FEW010CB BKN008 24/24 Q1010 TEMPO FM0300 AND 0430 -RA=Wind 260 degrees at 4 knots; 6000 m visibility in rain; few clouds with cumulonimbus at 1,000 ft; broken clouds 800 ft; Temperature24°C; Dew point 24°C; QNH 1010 hPa
05:00 UTC / 12:00 local time:
WIOO 020500Z 27009KT 7000 FEW010CB BKN008 25/24 Q1009 TEMPO AT 0500=
Follow-up / safety actions
NTSC issued 7 Safety Recommendations
Issued: 26-AUG-2016 | To: Pontianak Airport | 04.B-2016-91.1 |
There were indications of hydroplaning on No 3 tire and mark of all tires on the paved surface after the runway end. This condition is classified as a hazard that might contribute and endanger the safety of the flight. Therefore, the KNKT recommends to airport authority to be aware and takes necessary safety action to minimize the risk. (CLOSED) |
Issued: 26-AUG-2016 | To: Pontianak Airport | 04.B-2016-92.1 |
Refer to the finding number 20, the passengers were not guided and assisted during the evacuation process. It considers to be evaluated refer to aerodrome operator policy. |
Issued: 26-AUG-2016 | To: DGCA Indonesia | 04.R-2016-93.1 |
Refer to the ICAO Annex 19 sub chapter 7 The DGCA shall implement documented surveillance processes, by defining and planning inspections, audits, and monitoring activities on a continuous basis. Therefore, the KNKT recommends for proactively assure the oversight and ensure that the recommendations issued in this final report were implemented correctly by the addressee and other related operators. |
Issued: 10-OCT-2016 | To: Lion Air | 04.O-2016-1.4 |
The aircraft was un-stabilized approach since 1000 feet to 50 feet above the threshold and the pilot decided to land the aircraft, this condition might be extended to the other crew. As such, the enforcement of the crew disciplines factors shall be improved |
Issued: 10-OCT-2016 | To: Lion Air | 04.O-2016-20.3 |
Refer to the finding number 20, the passengers were not guided and assisted during the evacuation process. It considers to be evaluated refer to company policy. |
Issued: 10-OCT-2016 | To: Lion Air | 04.O-2016-90.1 |
Learn from this accident, it is strongly required that the maintenance department to be consistent with the Aircraft Maintenance Manual (AMM) for any aircraft technical and system rectification guidance. |
Issued: 10-OCT-2016 | To: Lion Air | PK-LIQ (1) |
The NTSC recommended to the PT. Lion Mentari Airlines, to improve the quality of training, including ALAR (Approach Landing Accident Reduction). |
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Photos

accident date:
02-11-2010type: Boeing 737-4Y0
registration: PK-LIQ

accident date:
02-11-2010type: Boeing 737-4Y0
registration: PK-LIQ

accident date:
02-11-2010type: Boeing 737-4Y0
registration: PK-LIQ

FDR data

PK-LIQ

accident date:
02-11-2010type: Boeing 737-4Y0
registration: PK-LIQ
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Jakarta-Soekarno-Hatta International Airport to Pontianak-Supadio Airport as the crow flies is 728 km (455 miles).
Accident location: Approximate; accuracy within a few kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.