Date & Time: Apr 13, 2013 at 1510 LT
Type of aircraft:
Boeing 737-800
Bandung - Denpasar
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On final approach to Denpasar-Ngurah Rai International Airport in Bali, aircraft was too low and crashed into the sea about one NM short of runway 09. All occupants were rescued while the aircraft broke in two and was damaged beyond repair. At the time of the accident, weather conditions were as follow : wind changing from 110 to 270 at six knots, cumulonimbus at 1,700 feet and unlimited visibility. Brand-new, the aircraft was delivered two weeks ago to Lion Air. Radar data suggest the aircraft was about 100 feet below a 3 degrees glide path descending at 700 feet per minute at a speed between 126 and 135 knots, descending through 200 feet MSL about 1 NM short of the touch down zone and 0.6 NM short of the sea wall. According to preliminary investigations, while descending through 900 feet, the copilot stated that the runway was not in sight. At 15:09:33, after the EGPWS called out "Minimum" at an altitude of approximately 550 ft AGL, the pilot disengaged the autopilot and the auto throttle and continued the descent. Twenty seconds later, at 150 ft AGL the captain took over control. The copilot handed the control to the captain and stated that he could not see the runway. At 15:10:01, the EGPWS called out "Twenty", and the captain commanded a go around. One second later the aircraft impacted the water. The aircraft stopped facing to the north at about 20 meters from the shore or approximately 300 meters south west of the beginning runway 09.
The National Transportation Safety Committee initial findings on the accident flight are as follows:
a. The aircraft was airworthy prior to impact and has an item on the DMI (deferred maintenance item) category C (right engine oil filter).
b. All crew has valid licenses and medical certificates.
c. The Second in Command (SIC) acted as Pilot Flying (PF).
d. The flight performed a VOR DME approach runway 09, and the published Minimum Descent Altitude (MDA) was 465 ft AGL.
e. The approach configuration used was flap 40.
f. At 900 ft AGL the PF did not have the runway in sight.
g. Upon reaching the MDA the flight profile indicated a constant path.
h. The PIC took over control of the aircraft at about 150 ft radio altitude.
i. The SIC handed over control to the PIC at about 150 ft and stated that he could not see the runway.
j. The final approach phase of the flight profile was outside the envelope of the EGPWS warning, therefore no EGPWS warning was recorded on the CVR.
The NTSC concluded in its final report that the accident was caused by the following factors:
- The aircraft flight path became unstable below minimum descends altitude (MDA) with the rate of descend exceeding 1000 feet per minute and this situation was recognized by both pilots.
- The flight crew loss of situational awareness in regards of visual references once the aircraft entered a rain cloud during the final approach below minimum descends altitude (MDA).
- The PIC decision and execution to go-around was conducted at an altitude which was insufficient for the go-around to be executed successfully.
- The pilots of accident aircraft was not provided with timely and accurate weather condition despite the weather around the airport and particularly on final approach to the airport was changing rapidly.
Final Report: