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KNKT
Penerbangan Final Report Accident

Boeing 737-Max 8 PK-LQP — Tanjung Karawang

Nomor investigasi
KNKT.18.10.33.04
Waktu kejadian
Lokasi
Tanjung Karawang
Wilayah administratif
KARAWANG, JAWA BARAT

Kronologi & deskripsi kejadian

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Data teknis

Data teknis kejadian Boeing 737-Max 8 PK-LQP — Tanjung Karawang
Operator / maskapai Lion Air
Registrasi PK-LQP
Tipe pesawat Boeing 737-Max 8
Nomor penerbangan LNI610
MTOW above 5,700 kg
Tahun pembuatan 2018
Tipe operasi AOC 121
Fase penerbangan ENR
Jenis kejadian Loss of Control - Inflight
Teritori JAWA

Korban

189 orang Meninggal

Faktor penyebab & kontributor

Faktor penyebab belum tercatat pada basis data untuk kejadian ini.

Sarana & operator terkait

Daftar sarana dan operator yang terlibat
Operator Flight Number Registrasi Tipe Pesawat Mtow Tahun Pembuatan Tipe Operasi
Lion Air LNI610 PK-LQP Boeing 737-Max 8 above 5,700 kg 2018 AOC 121

Rekomendasi keselamatan yang diterbitkan

Penerima: Airnav Indonesia Ats Provider / Airnav Indonesia

  • 04.A-2018-35.03 CLOSED 1 tanggapan

    KNKT recommends providing information to the flight crew that the altitude indication on the ATC radar display was repeating data from the aircraft

    Lihat butir & lini masa tanggapan

Penerima: Batam Aero Technic Bengkel Pesawat

  • 04.A-2018-35.04 CLOSED 1 tanggapan

    KNKT recommends emphasizing engineers to record test values as required by the BAT LMPM

    Lihat butir & lini masa tanggapan
  • 04.A-2018-35.05 CLOSED 1 tanggapan

    KNKT recommends establishing system to ensure the company manuals are updated in timely manner.

    Lihat butir & lini masa tanggapan
  • 04.A-2018-35.06 CLOSED 1 tanggapan

    KNKT recommends that Batam Aero Technic establish policy and procedure of handling OMF

    Lihat butir & lini masa tanggapan

Penerima: Boeing Company Pabrik Pesawat Udara

  • 04.M-2018-35.07 CLOSED 1 tanggapan

    KNKT recommends that the aircraft manufacture to consider the effect of all possible flight deck alerts and indications on flight crew recognition and response; and incorporate design, flight crew procedures, and/or training requirements where needed to minimize the potential for flight crew actions that are inconsistent with manufacturer assumptions

    Lihat butir & lini masa tanggapan
  • 04.M-2018-35.08 CLOSED 1 tanggapan

    KNKT recommends that Boeing include a larger tolerance in the design is required to allow operability by a larger population of flight-rated pilots

    Lihat butir & lini masa tanggapan
  • 04.M-2018-35.09 CLOSED 1 tanggapan

    KNKT recommends that Boeing and the FAA more closely scrutinize the development and certification process for systems whose malfunction has the ability to lead to loss of control of the airplane.

    Lihat butir & lini masa tanggapan
  • 04.M-2018-35.10 CLOSED 1 tanggapan

    KNKT recommends to Boeing to develop the guidance for the criteria of information which should be included in flight crew and engineer’s manuals

    Lihat butir & lini masa tanggapan
  • 04.M-2018-35.11 CLOSED 1 tanggapan

    KNKT recommends to Boeing that they ensure that certified and delivered airplanes have intended system functionality

    Lihat butir & lini masa tanggapan
  • 04.M-2018-35.12 CLOSED 1 tanggapan

    KNKT recommends the IFIM tasks sequence are reviewed to ensure they are effective.

    Lihat butir & lini masa tanggapan

Penerima: Directorate General of Civil Aviation Regulator Indonesia

  • 04.R-2018-35.13 OPEN 1 tanggapan

    KNKT recommends improving oversight to ensure implementation of the standard procedure.

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.14 OPEN 1 tanggapan

    KNKT recommends improving the oversight of the manual to ensure the manuals are conform to the standard and updated in timely manner

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.15 OPEN 1 tanggapan

    KNKT recommends that the Directorate General of Civil Aviation review operators SMS training material and the duration of training to ensure adequacy of SMS implementation

    Lihat butir & lini masa tanggapan

Penerima: Lion Air Operator Pesawat

  • 04.R-2018-35.16 CLOSED 1 tanggapan

    KNKT recommends establishing system to ensure the company manuals are updated in timely manner.

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.17 CLOSED 1 tanggapan

    KNKT recommends that Lion Air review the SMS training material and the duration of training

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.18 CLOSED 1 tanggapan

    recommends that Lion Air improve their hazard report management enabling identifying the hazard and provides proper mitigation.

    Lihat butir & lini masa tanggapan

Penerima: Lion Air Operator Pesawat

  • 04.O-2018-35.02 CLOSED 1 tanggapan

    According to the weight and balance sheet, on board the aircraft were two pilots, five flight attendants and 181 passengers consisted of 178 adult, one child and two infants. The voyage report showed that the number of flight attendant on board was six flight attendants. This indicated that the weight and balance sheet did not contain actual information.KNKT recommend ensuring all the operation do...

    Lihat butir & lini masa tanggapan
  • 04.O-2018-66.01 CLOSED 1 tanggapan

    Refer to the CASR Part 91.7 Civil Aircraft Airworthiness and the Operation Manual part A subchapter 1.4.2, the pilot in command shall discontinue the flight when un-airworthy mechanical, electrical, or structural conditions occur.The flight from Denpasar to Jakarta experienced stick shaker activation during the takeoff rotation and remained active throughout the flight. This condition is considere...

    Lihat butir & lini masa tanggapan

Penerima: United States Federal Aviation Administration Regulator Asing

  • 04.R-2018-35.19 CLOSED 1 tanggapan

    KNKT recommends to review the requirements of the applicable FARs to consider any issue that may be overlooked when the requirements are considered separately

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.20 CLOSED 1 tanggapan

    KNKT recommends that the FAA review their processes for determining their level of involvement (degree of delegation) and how changes in the design are communicated to the FAA to ensure an appropriate level of review

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.21 CLOSED 1 tanggapan

    KNKT recommends that the FAA improves the oversight to Approved Maintenance Organization (AMO) to ensure the processes within the AMO are conducted in accordance with the requirements

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.22 CLOSED 1 tanggapan

    KNKT recommends that Boeing and the FAA more closely scrutinize the development and certification process for systems whose malfunction has the ability to lead to loss of control of the airplane

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.23 CLOSED 1 tanggapan

    KNKT recommends that the FAA work with international regulatory authorities to review assumptions on flight crew behavior used during design and revise certification processes to ensure assumptions used during the design process are validated.

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.24 CLOSED 1 tanggapan

    KNKT recommends to the FAA work with international regulatory authorities to review the guidance for the criteria of information which should be included in flight crew and engineer’s manuals

    Lihat butir & lini masa tanggapan
  • 04.R-2018-35.25 CLOSED 1 tanggapan

    KNKT recommends to Boeing and the FAA that they ensure that certified and delivered airplanes have intended system functionality

    Lihat butir & lini masa tanggapan

Penerima: Xtra Aerospace Bengkel Pesawat

  • 04.R-2018-66.26 TDTL 1 tanggapan

    KNKT recommends emphasizing the implementation of a company manual including equivalency assessment, training and written procedure, to ensure component being repaired are properly maintained

    Lihat butir & lini masa tanggapan