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29 Apr 2018 - PK-LOO 737-800 Runway excursion after landing

On 29 Apr 2018 Lion Air 737-800, PK-LOO (39814/4879 delivered Apr 2014), departed to the left side of runway 27 at Gorontalo (WAMG) whilst landing in rain at 1030z. There was aircraft damage but no injuries.

WAMG 291730Z 17001KT 5000 RA BKN010CB 24/23 Q1009 RMK CB IN APCH=

The Indonesian NTSC released their preliminary report on 8 Aug 2018. The findings and safety actions are given below.

A summary of the findings is that the aircraft immediately ahead reported heavy rain on the approach. The aircraft touched down, the spoiler automatically deployed and the PF selected the engine thrust reversers. The pilots felt that suddenly the rain became very heavy and only able to see the runway lights on the left side of the runway. The aircraft stopped on the left side runway shoulder at approximately 1,200 meters from the beginning runway 27 and the aircraft heading was 310°. After completion of the Emergency on Ground procedure, the pilot unable to communicate with the controller and the Passenger Address system did not work. The instruction for evacuation was provided verbally direct to the Flight Attendant 1. No one injured in this accident and the aircraft substantially damaged. The nose landing gear collapsed backward and impacted the forward lower fuselage resulted in dent on this area. The engine cowlings broken. Two runway lights were found broken.

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PK-LOO runway overrun

Photo: M. Yasir

Findings

1. The aircraft had valid Certificate of Airworthiness (C of A) and Certificate of Registration (C of R).

2. The pilots held valid licenses and medical certificates.

3. On the first contact, when the aircraft was maintained 33,000 feet, the weather condition reported was wind calm, visibility 2,500 meters, weather slight rain, cloud FEW CB (cumulonimbus) 800 feet and overcast 800 feet, with additional remark that the CB on approach area. The weather condition was above the minima requirement for instrument approach runway 27.

4. A pilot of an ATR aircraft that previously landed informed to the LNI 892 pilot that when they were making the approach the final area was heavy rain. The LNI 892 pilot acknowledged the information.

5. The Automatic Weather Observation System (AWOS) of the meteorology station Gorontalo was unserviceable 5 days before the accident flight. The unserviceable AWOS had made up date weather information did not available in the tower cab. The controller should call to BMKG observer requesting the update weather information.

6. At 1040 UTC, the aircraft touched down, the spoiler automatically deployed and the PF selected the engine thrust reversers. The pilots felt that suddenly the rain became very heavy and only able to see the runway lights on the left side of the runway.

7. The aircraft stopped on the left side runway shoulder at approximately 1,200 meters from the beginning runway 27 and the aircraft heading was 310°.

8. After completion of the Emergency on Ground procedure, the pilot unable to communicate with the controller and the Passenger Address system did not work. The instruction for evacuation was provided verbally direct to the Flight Attendant 1 (FA 1).

9. The FA 1 and FA 4 initiated the passenger evacuation from the forward cabin doors, while FA 5 who was on the center cabin and FA 2 and FA 3 who were on the aft cabin did not know that the passenger evacuation had been initiated and did not initiated passenger evacuation.

10. The Djalaluddin Tower controller could not clearly see the aircraft position however, the controller aware that the aircraft experienced abnormality. The controller notified the Airport rescue and Fire Fighting (ARFF) by handy talky radio since the crash bell had not been connected to the new location of the ARFF station.

11. The ARFF personnel after received notification immediately proceed to the position of aircraft stopped to assist the evacuation.

12. No one injured in this accident and the aircraft substantially damaged. The nose landing gear collapsed backward and impacted the forward lower fuselage resulted in dent on this area. The engine cowlings broken. Two runway lights were found broken.

Safety Actions

At the time of issuing this Preliminary Report, the KNKT had been informed of safety actions taken by aircraft operator resulting from this accident. The safety actions consisted of corrective training for both pilots including simulator training and flight attendants on duty which focused on emergency procedure. The Safety and Security Directorate issued safety recommendations for related department:

1. To add scenario on recurrent simulator for all pilots, including tire-cornering and wave-off exercises.

2. To revise all the OM-C that states “No take-off or landing in heavy rain. When the RWY is contaminated” to “No take-off or landing in heavy rain or when the RWY is contaminated”

3. To revise the OM-C on WAMG/GTO for VOR DME approach RWY 27 into step by step procedures and specified the final approach fix is changed to the 12 Nm point (CF27) and landing configuration has been achieved.

4. Obtain approval from regulator (DGCA) for Lion Air of RNAV (GNSS) approach.

5. to review evacuation procedure.

6. To determine alternate signal for command “evacuate” when PA/interphone communication system suddenly failed, to the following example of, in the condition such FA1 identify that PA system is fail to function, immediately she/he will use megaphone to initiate evacuation command.

7. To include “increasing situational awareness in any abnormal condition” into ‘one-minute silent review’ item. The Safety and Security Directorate also issued Safety Information for all pilots (detail is attached on the Appendices of this report) contained:

1. To respect of Stabilization Approach criteria

2. To respect of Mandatory Missed Approach criteria

3. To increase awareness when weather deterioration occurs such as time by time visibility reduction

4. To ensure, implement anything related to requirement, prohibition or limitation stated in OM-C

5. To review crew coordination and standard call out during approach

6. To increase crew assertiveness, particularly as pilot monitoring

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