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PenerbanganFinal ReportAccident

Boeing 737-800 PK-LKS — I Gusti Ngurah Rai Airport, Bali

Nomor investigasi
KNKT.13.04.09.04
Waktu kejadian
Lokasi
I Gusti Ngurah Rai Airport, Bali
Wilayah administratif
BADUNG, KEPULAUAN BANGKA BELITUNG

Kronologi & deskripsi kejadian

During the final approach at runway 09, the aircraft came down into water. The crew conducted a ditching procedure evacuation to disembark all passengers. The investigation is continuing

Data teknis

Data teknis kejadian Boeing 737-800 PK-LKS — I Gusti Ngurah Rai Airport, Bali
Operator / maskapaiLion Air
RegistrasiPK-LKS
Tipe pesawatBoeing 737-800
MTOWabove 5,700 kg
Tipe operasiAOC 121
Fase penerbanganApproach (APR)
Jenis kejadianUndershoot/Overshoot
Jenis kejadian IIUndershoot

Faktor penyebab & kontributor

Faktor I
Human; Human; Human; Human

Sarana & operator terkait

Daftar sarana dan operator yang terlibat
OperatorFlight NumberRegistrasiTipe PesawatMtowTahun PembuatanTipe Operasi
Lion Air—PK-LKSBoeing 737-800above 5,700 kg—AOC 121

Rekomendasi keselamatan yang diterbitkan

Penerima: AirNav Indonesia

  • —CLOSED0 tanggapan

    The ATIS information of the visibility was 10 km contrary to the actual condition that the pilots could not see the runway. Considered to this finding KNKT recommends that the AirNav Indonesia should adjust the airport operation according to the current firefighting and rescue category, declared by airport authority

    Lihat butir & lini masa tanggapan

Penerima: Angkasa Pura I

  • —CLOSED0 tanggapan

    While foam tender(s) absence from the fire station, the requirement of ICAO for the response time and firefighting category should be complied therefore requires specific strategy. If the response time could not be achieved, the airport operation should be reduce or stop for evaluating purposes.

    Lihat butir & lini masa tanggapan
  • —CLOSED0 tanggapan

    In regard to the actual time of the ARFF arrival at the accident site and the ICAO Annex 14 Para 9.2.23 recommended response time indicated that the actual response time performed by the ARFF was 4 minutes instead of 3 minutes after the crash bell pressed by controller. Following to this finding the PT Angkasa Pura I requires to evaluate the ARFF response time capability based on the involvement o…

    Lihat butir & lini masa tanggapan

Penerima: Badan Meteorologi Klimatologi dan Geofisika

  • —OPEN0 tanggapan

    The BMKG and AP I should evaluate the current information distribution system to ensure the latest weather information distributes to the pilots representing the ICAO Recommendation

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The ICAO Annex 3 4.6, Observing and reporting of visibility, should be implemented

    Lihat butir & lini masa tanggapan

Penerima: Directorate General of Civil Aviation

  • —OPEN0 tanggapan

    The DGCA should oversight the ARFF response time capability, including in the case of the firefighting and rescue category downgraded due to firefighting and rescue activities

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The DGCA should oversight all air operators in achieving the effectiveness of training programs for the pilots to be competent in hand flying and covered during pilot initial training and recurrent program.

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The DGCA should oversight all air operators in reviewing the effectiveness of current Safety Emergency Procedure particularly evacuation procedure

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The DGCA should oversight all air operators to ensure pilot monitoring skills are embedded in the pilot training program and SOP

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The DGCA should oversight all air operators to ensure the effectiveness of current CRM training program and CRM practices

    Lihat butir & lini masa tanggapan

Penerima: Lion Air

  • —OPEN0 tanggapan

    The operator should review and ensure the effectiveness of current CRM training program and CRM practices.

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The operator should emphasize and ensure pilot monitoring skills are embedded in the pilot training program and SOP

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The operator should ensure that all pilots must be competent in hand flying and covered during pilot initial and recurrent training program

    Lihat butir & lini masa tanggapan
  • —OPEN0 tanggapan

    The operator should review and ensure the effectiveness of current Safety Emergency Procedure particularly evacuation procedure.

    Lihat butir & lini masa tanggapan