Casualties unknown

2016-02-20: Boeing 737-900ER (PK-LFG) — Lion Air — Juanda International Airport, Surabaya, ID

Juanda International Airport, Surabaya, ID

On February 20, 2016, a Boeing 737-900ER (registration PK-LFG) operated by Lion Air was involved in an aviation accident near Juanda International Airport, Surabaya, ID. Investigators recorded the probable cause as: The difficulty to control the aircraft and deteriorating weather did not trigger firm action, resulting in a combination of lack of communication and leadership; and the combination of prolonged touchdown, delay in spoiler deployment, thrust levers not at… This summary draws on records from the Indonesian National Transportation Safety Committee (KNKT); 14 related events involving the same aircraft type or operator are linked below.

Sourcesthe Indonesian National Transportation Safety Committee (KNKT)Primary reportUpdated 1785107694Data APIEditorial standards
Boeing 737-900ER
Photo: San Diego Air & Space Museum Archives / Public domain, via Wikimedia Commons

On 20 February 2016, a Lion Air Boeing 737-900ER overran the runway at Juanda International Airport after a landing with delayed deceleration devices. No injuries or damage occurred.

Introduction

On 20 February 2016, a Boeing 737-900ER, registration PK-LFG, operated by PT. Lion Mentari Airlines as flight LNI263, overran the runway after landing at Juanda International Airport, Sidoarjo, East Java, Indonesia. The aircraft had departed Sepinggan International Airport, Balikpapan, at 0230 UTC (1030 local time) on a scheduled passenger flight. On board were two pilots, five flight attendants, and 215 passengers.

Flight History

During the approach to Surabaya, the Pilot in Command (PIC) acted as Pilot Monitoring (PM) and the Second in Command (SIC) as Pilot Flying (PF). At 0403 UTC, the crew received clearance for an Instrument Landing System (ILS) approach to runway 10. While descending through 2,500 feet, the pilots discussed cloud formation and observed magenta clouds on the flight path. At 0404 UTC, the autopilot disengaged uncommanded but was re-engaged after eight seconds. At 0406 UTC, while passing 600 feet, both autopilot and autothrottle disengaged, and the pilots flew manually. On final approach, Air Traffic Control broadcast that visibility had decreased to 1,000 meters. On short final, the PIC noticed the SIC had difficulty controlling the aircraft and assisted in correcting the approach profile.

The aircraft touched down at approximately 552 meters from the runway threshold with a speed 9 knots above the target. After touchdown, the thrust reverser levers could not be selected because the thrust levers were not at idle. Spoiler deployment was delayed by about 10 seconds, and brake pressure increased 9 seconds after touchdown. The aircraft overran the runway and stopped with the nose wheel approximately one meter off the pavement. No injuries or damage were reported.

Investigation Findings

The investigation determined that the difficulty controlling the aircraft and the deteriorating weather did not trigger firm action, resulting in a combination of lack of communication and leadership. Additionally, the combination of prolonged touchdown, delay in spoiler deployment, thrust levers not at idle, and late brake application affected the landing distance.

Contributing Factors

The following contributing factors were identified:

  • The difficulty to control the aircraft and deteriorating weather did not trigger firm action, resulting in a combination of lack of communication and leadership.
  • The combination of prolonged touchdown, delay in spoiler deployment, thrust levers not at idle, and late brake application affected the landing distance.

Safety Actions

Following this serious incident, PT. Lion Mentari Airlines issued safety actions considered relevant to improve safety. The Komite Nasional Keselamatan Transportasi (KNKT) also issued safety recommendations addressed to PT. Lion Mentari Airlines and the Directorate General of Civil Aviation.

Probable cause

The difficulty to control the aircraft and deteriorating weather did not trigger firm action, resulting in a combination of lack of communication and leadership; and the combination of prolonged touchdown, delay in spoiler deployment, thrust levers not at idle, and late brake application affected the landing distance.