What happened
On 1 February 2014, a Lion Air Boeing 737-900ER, registration PK-LFH, was operating a passenger flight from Sepinggan International Airport in Balikpapan to Juanda International Airport in Surabaya. During the approach to runway 28, the autopilot disconnected at 1,000 feet amidst reported winds of 16 knots.
Upon arrival at Juanda International Airport, the aircraft experienced a sequence of multiple bounced landings. The final touchdown was a heavy impact, recorded at 3.866 G. The force of the landing caused the tail skid indicator to contact the runway and resulted in significant structural damage to the airframe. While the aircraft was able to taxi to its parking stand, the impact caused the nose wheel hub to break and one main tire to go flat. Additionally, skin wrinkling was identified on both the left and right sides of the fuselage.
Of the 225 people on board, two passengers suffered serious injuries and three others sustained minor injuries. All passengers were able to disembark normally, and the injured were transported to the airport medical clinic.
The investigation
The investigation by the NTSC focused on the mechanical state of the aircraft and the flight crew's performance. Investigators examined the aircraft's maintenance history, noting a recent report regarding light elevator control movement following hydraulic pump activation. Functional checks of the elevator control artificial feel were also conducted.
Furthermore, the investigation reviewed the crew's training records and the airline's Company Operation Manual (COM). It was noted that the flight crew had not received specific training for bounced landing recovery or rejected landing procedures. The investigation also looked into the pairing of the crew members in relation to the company's experience-based operational limitations.
Findings
- The aircraft sustained substantial damage, including a broken nose wheel hub, tail skid damage, and fuselage skin wrinkling.
- The landing sequence involved a series of bounces, culminating in a high-G impact.
- The flight crew had not undergone training for bounced landing recovery or rejected landing exercises.
- There were discrepancies noted in the elevator control artificial feel values during functional testing.
Safety action
The NTSC has recommended that Lion Air review its training programs regarding bounced landing recovery and rejected landing procedures. Additionally, the airline is advised to ensure that crew pairings strictly adhere to the experience limitations outlined in the Company Operation Manual and to investigate the cause of the elevator control artificial feel deviations.