ASN Aircraft accident Boeing 737-9GPER (WL) PK-LJZ Medan-Kualanamu International Airport (KNO)
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Status:Accident investigation report completed and information captured
Date:Thursday 3 August 2017
Time:11:00
Type:Silhouette image of generic B739 model; specific model in this crash may look slightly different
Boeing 737-9GPER (WL)
Operator:Lion Air
Registration: PK-LJZ
MSN: 37296/4128
First flight: 2009-07-16 (8 years )
Total airframe hrs:13773
Cycles:10213
Engines: 2 CFMI CFM56-7B26E
Crew:Fatalities: 0 / Occupants: 7
Passengers:Fatalities: 0 / Occupants: 144
Total:Fatalities: 0 / Occupants: 151
Aircraft damage: Substantial
Aircraft fate: Repaired
Location:Medan-Kualanamu International Airport (KNO) (   Indonesia)
Phase: Landing (LDG)
Nature:Domestic Scheduled Passenger
Departure airport:Banda Aceh-Sultan Iskandarmuda Airport (BTJ/WITT), Indonesia
Destination airport:Medan-Kualanamu International Airport (KNO/WIMM), Indonesia
Flightnumber:JT197
Narrative:
An ATR 72-500 operated by Wings Air as flight 1252 (PK-WFF) and a Boeing 737-900 operated by Lion Air as flight 197 (PK-LJZ) both sustained substantial damage in a ground collision accident on the active runway 23 at Medan-Kualanamu International Airport, Indonesia.
The ATR 72-500 operated as scheduled passenger flight from Medan with intended destination of Meulaboh Airport. On board IW1252 were two pilots, one observer pilot, two flight attendants and 67 passengers. The pilot in command acted as Pilot Flying (PF) and the second in command acted as Pilot Monitoring (PM).
At 10:54, the flight attendant of IW1252 advised the pilot that the boarding process was completed. The pilot then requested push back and engine start clearance from the Medan Ground controller , which was approved.
At 10:56, IW1252 requested taxi clearance to the Medan Ground controller and was instructed to taxi to runway 23 following U2 taxi route, which was from apron V to holding point runway 23 on taxiway C, via taxiway U - T - and B.
At 10:57, flight JT197 reported to the Medan Tower controller that the aircraft was established on the localizer of runway 23. The Medan Tower controller acknowledged this and issued a landing clearance with additional information regarding the wind conditions and barometric pressure.
At 10:58, IW1252 contacted Medan Tower and was instructed to continue to taxi and hold on short of runway 23. Flight IW1252 requested to depart via the taxiway D intersection with the intention to expedite the departure. This was approved. Taxiway D was a Rapid Exit Taxiway (RET) for runway 05.
At 10:59, IW1252 advised Medan Tower that the aircraft was close to reaching runway 23. Medan Tower then requested confirmation that IW1252 was ready for immediate departure. There was no reply and the Medan Tower controller repeated the request and received the reply that IW1252 was able for immediate departure.
Medan Tower intended to let IW1252 depart immediately after flight JT197 had landed, since there was another arriving aircraft behind JT197.
At 11:00:01, the Medan Tower controller radioed: "Wings Abadi one two five two behind traffic Lion short final landed passing line up behind runway two three from intersection delta additional clearance after departure direct Meulaboh".
At 11:00:13, IW1252 read back: "after departure direct to Meulaboh Wings Abadi one two five two". Thereafter, IW1252 continued the taxi for line up on runway 23.
At 11:00:32, IW1252 crossed the runway holding position marking (yellow line). At the same time, the Medan Tower controller was monitoring the distance of the second arriving aircraft on the radar display.
As JT197 was on short final, the flight crew noted IW1252 ahead and assumed that the ATR aircraft would not enter the runway. Therefore, the PF decided to continue the landing approach and focused on handling the aircraft.
At 11:00:50, JT197 touched down and the attention of the Medan Tower controller changed back from the radar display to the runway environment.
IW1252 by then crossed the runway side marking (white line) and continued to enter the runway. The flight crew of JT197 saw that the ATR was entering the runway.
At 11:00:56, the left wing of JT197 impacted with the right hand wing of IW1252.
The flight crew of JT197 subsequently radioed the Medan Tower controller that there was another aircraft on the runway and this was acknowledged. The Medan Tower supervisor on duty noticed two aircraft on the runway and the Medan Tower controller panicked. Thereafter, the Medan Tower supervisor took over the communication of Medan Tower.
At 11:01:47, the pilot of JT197 contacted the Medan Tower twice, and received a response at 11:02:01 by the Medan Tower supervisor, who then instructed them to vacate the runway via taxiway G.
At 11:02:05, JT197 advised the Medan Tower that the aircraft had touched down and asked why there was another aircraft on runway 23. The Medan Tower supervisor requested the pilot to standby.
At 11:02:30, the Medan Tower supervisor instructed the other arriving aircraft pilot to overshoot due to traffic. The other arriving aircraft pilot requested to make orbit to the left on final approach which was approved.
While the Boeing 737-900 was taxiing to the parking bay, the Medan Tower supervisor issued takeoff clearance to IW1252, with additional clearance to turn left heading 315 after airborne. IW1252 responded that they were unable to depart. The Medan Tower supervisor then instructed the IW1252 pilot to hold on the runway.
At 11:04:40, the Medan Tower supervisor again issued takeoff clearance IW1252, to which the pilot responded by requesting to return to the apron for inspection of any damage to the aircraft. The Medan Tower supervisor approved the request and instructed them to vacate the runway via taxiway E then to contact Medan Ground.
As the ATR was taxiing back to the apron another departing aircraft was cleared to line up on runway 23, with takeoff clearance being issued at 11:07:21.
At 11:08:55, JT197 advised the Medan Ground controller pf the possibility of aircraft debris on the runway that might become hazard to the other aircraft. The Medan Ground controller acknowledged and relayed the information to Medan Tower supervisor. At 11:10:26, the flight that had just departed advised Medan Tower that there was Foreign Object Debris (FOD) on the runway.
Despite these reports, Medan Tower issued landing clearance to another arriving aircraft at 11:10:44.
At 11:14, after landing on runway 23, the other arriving flight advised Medan Tower that there was FOD on the runway. It took until 11:31 for the runway to be closed. After all the debris were collected and runway cleaned, the runway was reopened and resumed to normal operation at 11:55.

Probable Cause:

Contributing Factors: "The communication misunderstanding of the conditional clearance to enter runway while the IW1252 pilots did not aware of JT197 had received landing clearance and the unobserved IW1252 aircraft movement made the IW1252 aircraft entered the runway."

Accident investigation:

cover
Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 259 days (9 months)
Accident number: KNKT.17.08.25.04
Download report: Final report

Classification:
Language/communication problems
Runway incursion
Runway mishap

METAR Weather report:
03:30 UTC / 10:30 local time:
WIMM 030330Z 08005KT 030V120 9000 BKN018 30/26 Q1010

04:00 UTC / 11:00 local time:
WIMM 030400Z 11007KT 040V140 9999 BKN018 30/25 Q1010

04:30 UTC / 11:30 local time:
WIMM 030430Z 06007KT 040V100 9999 BKN018 31/26 Q1009


Photos

photo of Boeing-737-9GPER-PK-LJZ
accident date: 03-08-2017
type: Boeing 737-9GPER
registration: PK-LJZ
photo of Boeing-737-9GPER-PK-LJZ
accident date: 03-08-2017
type: Boeing 737-9GPER
registration: PK-LJZ
photo of Boeing-737-9GPER-PK-LJZ
 

Video, social media

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 Banda Aceh-Sultan Iskandarmuda Airport to Medan-Kualanamu International Airport as the crow flies is 435 km (272 miles).
Accident location: Exact; deduced from official accident report.

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.
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