Investigation Summary
The accident occurred during a VOR DME approach to Runway 09. The First Officer was the Pilot Flying (PF) while the Captain served as Pilot Monitoring (PM). As the aircraft descended through the MDA of 466 feet, the crew encountered a localized rain cell that severely restricted visibility, described by the Captain as 'totally dark.' Although the First Officer repeatedly stated he could not see the runway, the Captain claimed to see approach lights and encouraged the descent to continue. The Captain took control at 150 feet, but failed to immediately initiate a go-around. The decision to abort the landing was finally made at 20 feet AGL, triggered by an EGPWS 'Twenty' callout. Because a Boeing 737 typically loses approximately 30 to 40 feet of altitude during the transition to a climb, the aircraft struck the water just one second after the go-around command.
Final Conclusions
The Indonesian National Transportation Safety Committee (NTSC) concluded in its final report (KNKT.13.04.09.04) that the primary causes were the crew's loss of situational awareness and the failure to adhere to basic instrument flying principles. The flight path became unstable below the MDA with a descent rate exceeding 1,000 feet per minute. The investigation also highlighted that the pilots were not provided with timely weather updates regarding the rapidly changing conditions on short final, and the Captain's go-around execution was initiated at an altitude that made impact inevitable.
Photographic Evidence (1)
Video Analysis
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Indonesian national, joined Lion Air in 2003.
First Officer
Indian national, joined Lion Air in 2011.
Systems & Failure Modes
EGPWS
The Enhanced Ground Proximity Warning System provided altitude callouts, including the 'Twenty' foot alert that finally prompted the Captain to attempt a go-around.
VOR DME Approach
A non-precision approach procedure used by the crew which required visual reference to the runway environment to descend below 466 feet.
Interesting Facts
- 01The aircraft was only 53 days old at the time of the accident, having logged 142 hours and 37 minutes of flight time.
- 02All 108 people on board survived the impact and subsequent evacuation into the shallow water.
- 03The investigation found no evidence of mechanical or engine failure prior to impact, though a deferred maintenance item existed for the right engine oil filter.
- 04The Captain had over 15,000 hours of total flight experience, while the First Officer had 1,200 hours.
- 05The aircraft came to rest in water approximately 20 meters from the shore.
Safety Actions & Advisories
Lion Air Training Review
The NTSC recommended that Lion Air review their pilot training regarding manual flying skills and the strict adherence to go-around procedures when visual references are lost below MDA.
Weather Reporting Improvements
Recommendations were made to improve the timeliness of weather information provided to pilots during rapidly changing meteorological conditions on final approach.
Known Controversies & Unanswered Questions
Drug Use Allegations
Reference ↗In 2017, the chief of Indonesia's national narcotics agency alleged the pilot was under the influence of drugs, but this was directly contradicted by the Transport Ministry's post-accident drug tests which were negative.