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The Indonesian KNKT have today released their final report into the runway overrun on landing of 737-400, PK-LIQ, 24911/2033, operated by Lion Air at Supadio Airport (WIOO) Indonesia on 2 November 2010. The aircraft overran after landing from an unstable approach in a tailwind. After touchdown there was no automatic speedbrake deployment and it was not manually selected until 42 seconds after touchdown. Furthermore the pilot reported that the thrust reverser was "hard to operate" and it was only selected 13 seconds after touch down. The aircraft overran the runway by 70m.

The crew were aware of difficulties in selecting thrust reversers and speed brake deployment on the aircraft. This had been previously reported 13 times but not successfully rectified by engineering.

The investigation concluded that the contributing factors were;

  • 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.

Report Sections:

  • SYNOPSIS
  • ANALYSIS
  • CONCLUSIONS
  • SAFETY RECOMMENDATIONS
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    The damage on the nose landing gear (Photo KNKT Report)

    SYNOPSIS

    On 2 November 2010, a Boeing Company B737-400 aircraft, registered PK-LIQ, was being operated by Lion Mentari Airlines as a passenger schedule flight with flight number JT 712 from Soekarno Hatta Airport, Jakarta at 10.12 LT (03.12 UTC) to Supadio Airport, Pontianak. The Pilot in Command (PIC) was the pilot flying (PF) and the Second in Command (SIC) was the pilot monitoring (PM).

    The crew aware that the aircraft has problem on the difficulty of selection the thrust reversers and automatic speed brake deployment. This problem has been reported 13 times.

    The flight to Pontianak was normal and the pilot performed ILS approach to runway 15 in slight rain and wet runway.

    The FDR recorded that the approach was un-stabilized according to the Boeing B737 FCTM and require for go around.

    After the aircraft touched down, the pilot reported that the thrust reverser was hard to operate and the speed brake did not auto-deploy. There was no deceleration felt by the crew. The FDR data revealed that the speed brake deployed 42 seconds after touchdown or 32 seconds after N1 increase.

    The aircraft run out of runway and stopped at approximately 70 meters from the runway or 10 meters from the stop-way pavement. The PIC commanded to the flight attendants for passenger evacuation. No one injured and all passengers were evacuated through all available exits.

    The investigation concluded that the contributing factors were;

    • 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.

    At the time of issuing this Final Report, the Komite Nasional Keselamatan Transportasi has not been informed of safety actions resulting from this accident.

    Includes in this final report, the KNKT issued several safety recommendations relates to operator maintenance program and flight operation procedures, wet runway safety and passenger survival aspects to the PT. Lion Air, PT. Angkasa Pura II Supadio Airport, Pontianak and Directorate General of Civil Aviation to address the safety issues identified in this final report.

    1.1 History of the Flight

    On 2 November 2010, a Boeing Company B737-400 aircraft, registered PK-LIQ, was being operated by Lion Mentari Airlines on a passenger schedule flight with flight number JT 712. This flight was the first flight for the crew and was scheduled for departure at 09.30 LT (02.30 UTC).
    On board the flight was 175 person included 2 pilots and 4 flight attendants and 169 passengers consisted 2 infants and one engineer.
    The pilots stated that the aircraft had history problem on the difficulty of selection the thrust reversers and automatic of the speed brake deployment. This problem was repetitive since the past three months.
    The aircraft pushed back at 0950 LT (0250 UTC). During taxi out, the yaw damper light illuminated for two times. The pilot referred to the Quick Reference Handbook (QRH) which guided the pilot to turn off the yaw dumper switch then back to turn on. Considered to these problems, the pilot asked the engineer to come to cockpit and asked to witness the problem.
    The aircraft departed Soekarno Hatta International Airport, Jakarta at 1012 LT (0312 UTC) with destination of Supadio Airport, Pontianak. The Pilot in Command acted as pilot flying (PF) and the Second in Command acted as pilot monitoring (PM). The flight to Pontianak until commenced for descent was uneventful.
    Prior to descend, the PF performed approach crew briefing with additional briefing included review of the past experiences on the repetitive problems of thrust reversers which sometimes hard to operate and the speed brake failed to auto deploy. Considering these problems, the PF asked to the PM to check and to remind him to the auto deployment of the speed brake after the aircraft touch down.
    During descend, the pilot was instructed by Pontianak Approach controller to conduct Instrument Landing System (ILS) approach for runway 15 and was informed that the weather was slight rain. On the initial approach, the auto pilot engaged, flaps 5° and aircraft speed 180 knots. After the aircraft captured the localizer at 1300 feet, the PF asked to the PM to select the landing gear down, flaps 15° and the speed decreased to 160 knots. The PF aimed to set the flaps landing configuration when the glide slope captured.
    When the glide slope captured, the auto pilot did not automatically follow the glide path and the aircraft altitude maintained at 1300 feet, resulted in the aircraft slightly above the normal glide path. The PF realized the condition then disengaged the auto pilot and the auto throttle simultaneously, and fly manually to correct the glide path by pushing the aircraft pitch down. While trying to regain the correct the glide path, the PF commanded for flaps 40° and to complete the landing checklist. The flap lever has been selected to 40°, but the indicator indicated at 30°. Realized to the flaps indication, the PF asked the landing speed for flaps 30° configuration in case the flaps could not move further to 40°.
    When aircraft altitude was 600 feet and the pilots completing the landing checklist, the PM reselected the flap from 30° to 40° and was successful.
    The pilots realized that the aircraft touched down was beyond the touchdown zone and during the landing roll the PF tried to select the thrust reverser but the levers were hard to select and followed by the speed brake failed to automatic-deploy. The pilots did not feel the deceleration, and then the PF applied maximum manual braking and selected the speed brake handle manually. Afterward, the thrust reversers successfully operated and a loud sound was heard prior to the aircraft stop. The Supadio tower controller on duty noticed that the aircraft was about to overrun the runway and immediately pressed the crash bell. The aircraft stopped at approximately 70 meters from the runway or 10 meters from the end of stop-way. The PIC then commanded to the flight attendants to evacuate the passengers through the exits. No one injured in this accident.

    1.3 Damage to Aircraft

    Field observation found that the aircraft severely damage, the damages were on the following sections: nose landing gear, right engine, nose section lower fuselage (aft of the nose wheel bay) and right engine.

    1.11.1 Solid State Flight Data Recorder (SSFDR)

    The significant events recorded by the FDR from 1000 feet until the aircraft
    stopped as follows:

    • The average sink rate of the aircraft between 1000 feet to 850 feet was 2500 ft/minutes.
    • The average sink rate of the aircraft between 550 feet to 450 feet was 1200 ft/minutes and the speed was 163 kts.
    • At 50 feet the aircraft speed 153 kts and the ground speed was 162 kts, or there was 9 kts of tail wind component.
    • The average ground speed during landing roll until aircraft stopped was 47 meter/second.
    • The aircraft deceleration started 13 seconds after touch down simultaneous to the increment of the N1’s, or equal to 611 meters from the touch down point.
    • Prior to aircraft stop the longitudinal acceleration decreased to -1.0 G’s for three seconds.
    • The speed brake deployed 42 seconds after touched down or 32 seconds after N1 increased at ground speed 1 which assumed that the aircraft has been stopped.

    1.12 Wreckage and Impact Information

    The aircraft run out of runway and stopped at approximately 70 meters from the runway end or 10 meters from the end of stop-way on heading 135°.
    The front left escape slide flatted and the tire no 3 ripped and also there were scratches as an indication of hydroplaning of the four wheel tires which shown along the stop way area of runway 15.

    2 ANALYSIS

    The analysis part of this Final Report will discuss the relevant issues resulting in the landing on taxiway involving a Boeing 737-400 aircraft registered PK-LIQ at Supadio Airport of Pontianak on 2 November 2010.
    The investigation determined that there were three relevant safety issues found which was associated with the approach profile, thrust reverser and automatic speed brake deployment to this occurrence.
    The analysis will therefore focus on the following issues;
     Auto speed brake control system
     Stabilized Approach
     Landing Distance Calculation

    2.1 The Auto Speed Brake Control System

    Investigation on the maintenance and reliability records related to the auto speed brake control system.
    There were 13 repetitive pilot reports (PIREP) of the speed brake fail for auto deployment (ATA 27) recorded since 03 September up to 27 October 2010. The maintenance rectifications carried out were:
     Clean the electrical plug of speed brake actuator motor,
     Repositioned control module,
     Clean and reposition relay R280 and R283, and
     Reposition and clean control plug actuator control speed.
    The rectification of the fail of automatic actuation of the speed brake control lever and system, refer to Aircraft Maintenance Manual (AMM) Chapter 27-62-00 page 104 were:
     Adjust or replace mechanism (page block 27-62-21/501),
     Adjust or replace arming switch (page block 27-62-34/401), or
     Replace actuator (Page block 27-62-31/401).
    Based on the interview with the PIC and SIC, it also noted that prior to descend the crew had aware that the problem related to the reverser and automatic spoiler deployment were still exist sometimes.
    In summary the AMM requires the adjustment or replacement of mechanism, arming switch and or the actuator. In fact, the investigation did not find evidence of the consistency of the rectifications and no evaluation and risk assessment program performed during the period in which the problem reported up to the occurrence. The aforesaid particular condition reappeared during the landing was might probably result of the unsolved symptom problems.

    2.2 Un-stabilized Approach and Decision to Land

    Refers to the Flight Crew Training Manual (FCTM) of the Boeing B 737 (revision July 29, 2011) page 5.4 it was stated that:
     the aircraft speed is not more than VREF +20 knots indicated airspeed and not less than VREF
     sink rate is no greater than 1,000 fpm; if an approach requires a sink rate greater than 1,000 fpm, a special briefing should be conducted
    Note: An approach that becomes un-stabilized below 1,000 feet AFE in IMC or below 500 feet AFE in VMC requires an immediate go-around.
    In fact, that the average sink rate of the aircraft between 1000 feet to 850 feet was 2500 ft/minutes and the average sink rate between 550 feet to 450 feet was 1200 ft/minutes. At 50 feet the aircraft speed was 162 kts or 24 knot above the Vref of 138 knots. There was 9 kts of tail wind component. These particular conditions indicated that the aircraft was un-stabilized since 1000 feet to 50 feet above the threshold, according to the Flight Crew Training Manual (FCTM) of the Boeing B 737 (revision July 29, 2011) page 5.4 which requires an immediate go-around.
    Crew Resource Management (FCTM Page 1.2) described that technique that help to build a good CRM habit pattern, such as stressing on Situational Awareness and communication.
    Situational awareness or the ability to accurately perceive what is going on in the flight deck and outside the airplane, requires ongoing monitoring, questioning, crosschecking, communication, and refinement of perception.
    It is important that all flight deck crewmembers identify and communicate any situation that appears unsafe or out of the ordinary. Experience has proven that the most effective way to maintain safety of flight and resolve these situations is to combine the skills and experience of all crewmembers in the decision making process to determine the safest course of action.
    Examination on the interview notes, the investigation did not find any of the crew communication or interaction respecting to their situational awareness while the aircraft was not aligning with the stabilized approach elements criteria. The conditions required the pilot assessment the ability to accurately perceive what was going on in the flight deck and outside the aircraft which required ongoing monitoring, questioning, crosschecking, communication, and refinement of their perception before the decision to land was made.

    2.3 Landing Distance Calculation

    The calculation of landing distance based on existing condition of weather, the weight and balance and condition recorded on the FDR refers to Flight Crew Operation Manual PI.32.3 Normal Configuration Landing Distance. The existing condition such as: the aircraft estimated landing weight at 55,589 kgs, at 50 feet aircraft speed was 153 kts, tail wind condition of 9 kts, temperature 26°C, braking action medium and maximum manual braking action. The calculations were as follows:

    Max manual braking : 4820 feet
    Landing weight adjustment : + 300 feet
    tail wind 10 knots : + 930 feet
    slope adjustment : -
    Temperature 11 above ISA : + 120 feet
    Speed 9 knots above target : + 380 feet
    Total landing distance required : 6,550 feet (2,041 meters)

    Examination on several events recorded by the FDR, it indicated 10 seconds after touched down the N1 gradually increased which it can be assumed as a result of the reverses deployment. The speed brake deployed 42 seconds after touchdown after the aircraft stopped. Further examination on the recorded aircraft speed, it indicated that the average ground speed after touchdown was 47 meter/second and the deceleration occurred 13 second after touchdown or it similar to 611 meters.
    Based on aforesaid calculation the required landing distance has penalty of 611 meters as consequences of the delay in deceleration of 13 seconds after touchdown.
    The calculations of the existing condition of 2,041 meters and the effect of the delayed of the reversers and deceleration resulted that the aircraft would require distance to stop which might reach to 2,652 meter, while the available landing distance was 2,250 meters.
    The FDR data revealed that the speed brake handle extended at 42 seconds after touchdown which the aircraft has stopped. This can be assumed that the speed brakes did not deploy during the landing roll. The landing distance calculation stated on the FCOM is based on the auto-deployment of the speed brake. Absence of the speed brake would prolong the landing distance.
    In fact, the aircraft stopped and trapped on the soft surface at 10 meters from the end of the pavement instead of 2,652 meters, it was consistent with the increasing of the deceleration up to 1.0 G’s for three seconds as recorded on the FDR.

    3 CONCLUSIONS

    3.1 Findings

    1. The aircraft was airworthy prior to this occurrence and was operated under a correct weight and balance envelope.
    2. All crew have valid licenses and medical certificates.
    3. Pilot in Command was the pilot flying (PF) and the Second in Command was the pilot monitoring (PM). The flight to Pontianak was reported normal and no abnormality reported and or recorded during the flight prior to the occurrence.
    4. On approach briefing prior to descend, the pilot flying reviewed the past experiences of this particular aircraft that the thrust reverser handles were hard to operate and the speed brake failed to auto deploy. The PF asked the PM to check and to remind the PF in respect to the auto deployment of the speed brake when aircraft touched down.
    5. Base on top ten PIREPS three months’ period, the speed brake control system trouble were 13 times reported and was the leading chapter.
    6. When conducting the ILS approach for runway 15, it was reported that the weather was slight rain.
    7. The last calibration of all the navigation aids at Supadio Airport was performed at 20 March 2010 and resulted in good condition.
    8. When the glide slope captured, the auto pilot failed to follow the glide path and the aircraft maintained at 1300 feet. The PF then fly manually to correct the flight path.
    9. As the flaps lever has been selected to 40, the flaps indicator indicated at 30 positions. Realized to the actual flaps indication, the PF asked to PM of the landing speed for that particular flaps position in case the flaps could not move further to 40.
    10. At 600 feet and the pilots completing the landing checklist, PM reselected the flap from 30° to 40° and was successful.
    11. Estimated landing weight was 55,300 kg and the Vref – flap 40 was 138 knots
    12. During on the interview, the pilots stated that the aircraft touched down beyond the touchdown point, and during the landing rolled, the PF tried to select the thrust reversers but it was difficult to operate and also the speed brake did not deploy automatically.
    13. The pilots stated that there was no deceleration felt by the crew the PF then applied maximum manual braking and selected the speed brake handle manually to deploy. Few seconds later the reversers activated normally. During the landing roll a loud bang was heard by the crew.
    14. Based on the interview, the Supadio Tower controller on duty stated that when the aircraft was about to run out of runway then he immediately pressed the crash bell.
    15. The aircraft run out of runway and stopped at approximately 70 meters from the runway or 10 meters from the end of stop-way.
    16. All passengers were evacuated through all available exits and all the escape slides were inflated. No one injured in this accident.
    17. Refer to the picture taken during the evacuation process (see figure 9), some passengers were standing on the wing carried their luggage and there was no person who assisted or guided the passengers.
    18. The FDR recorded shown:
    - Sink rate between 1000 feet to 850 feet was 2500 ft/minutes.
    - Sink rate between 550 feet to 450 feet was 1200 ft/minutes and the speed was 163 kts.
    - At 50 feet the aircraft speed 153 kts and the ground speed was 162 kts, or there was 9 kts of tail wind component.
    - The average ground speed during landing roll until aircraft stopped was 47 meter/second.
    - The aircraft deceleration occurred 13 seconds after touch down together with increment of the N1’s.
    - Prior to aircraft stopped the longitudinal acceleration decrease to -1.0 G’s for three seconds.
    - The speed brake deployed 42 seconds after touchdown or 32 seconds after N1 increase at ground speed 1 which assumed that the aircraft has been stopped
    19. The CVR data recorded during the flight and landing has been overwritten.
    20. There was no evidence of fire in-flight or after the aircraft impacted.
    21. The flaps were full down and speed brakes were on retracted position.
    22. Flight Crew Training Manual (FCTM) of the Boeing B 737 (revision July 29, 2011) page 5.4, shown the detail of recommended Elements of a Stabilized Approach. An approach that becomes un-stabilized below 1,000 feet AFE in IMC or below 500 feet AFE in VMC requires an immediate go-around.
    23. The aircraft speed was more than VREF +20 knots when approached below 1000 feet.
    24. Decision making in safety critical and time constrained situations largely relies on flight crews following a predetermined course of action, typically encapsulated in Standard Operating Procedures.
    25. The stabilized approach, thrust reverser and automatic speed brake system deployment were the issues related to this occurrence.
    26. Examination on the interview notes, the investigation did not find any of the crew communication or interaction respecting to their situational awareness while the aircraft was not aligning with the stabilized approach elements criteria.
    27. Related to auto speed brake deployment rectification the investigation referred to Aircraft Maintenance Manual (AMM) Chapter 27-62-00 page 104. The AMM requires the adjustment or replacement of mechanism, arming switch and or the actuator. In fact, the investigation did not find the consistency of the rectifications according to the AMM.
    28. The investigation did not find evidence of the consistency of the rectifications and no evaluation and risk assessment program performed during the period in which the problem reported up to the occurrence.
    29. Assuming reversers and auto speed brake deployment operative normally the total landing distance required would be 6,550 feet (2,041 meters).
    30. The calculations of the existing condition assuming reversers and auto speed brake deployment operative normally the total landing distance required would be 6,550 feet (2,041 meters) and the effect of the delayed of the reversers and deceleration resulted that the aircraft would require distance to stop which might reach to 2,652 meter, while the available landing distance was 2,250 meters.
    31. The aircraft stopped and trapped on the soft surface at 10 meters from the end of the pavement instead of 2,652 meters, it was consistent with the increasing of the deceleration up to 1.0 G’s for three seconds as recorded on the FDR.
    32. There were indications of hydroplaning on number 3 tire and mark of all tires on the paved surface after the runway end.

    3.2 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.

    4 SAFETY ACTIONS

    At the time of issuing this Draft Accident Investigation Report, the Komite Nasional Keselamatan Transportasi (KNKT) has not been informed of any safety actions resulting from this accident.

    5 SAFETY RECOMMENDATIONS

    The investigation identified safety issues contributed to this accident which were: un-stabilized approach, selection of the thrust reverser and automatic system of the speed brake deployment problem.
    Consider CRM perspective, the pilots decided to land the aircraft while some of the stabilize approach criteria did not meet to land the aircraft safely.
    The recommendations issued are based on the findings and analysis in this investigation, and the finding that classified as a safety hazard which may not be analyzed prior to issue a safety recommendation. However, the operators and the addressee of the recommendation shall consider that the condition possibly extends to other pilots, related operators as well as regulators.
    Concerning to the safety issues identified in this investigation, the Komite Nasional Keselamatan Transportasi issued several safety recommendations intended for the safety improvement and addressed to:

    5.1 PT.Lion Air

    The contributing factors described on 3.2 in this final report shown the queuing factors that highlighted as a back ground of the safety recommendations;
     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.
    Note: The Chapter 2. 2.1 Analyses describe the detail specifically.
     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.
    Note: Chapter 2.2.2 Analysis describes the detail of each single element went wrong of the SOP specifically.
     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.

    5.2 PT. Angkasa Pura II Supadio 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.
     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.

    5.3 Directorate General of Civil Aviation

     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.

    Full report here

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