Lion Air Flight 386

Infobox Airliner accident|name=Lion Air Flight JT-386
Crash

Date=January 14, 2002
Type=Failure to takeoff, Pilot error
Site=Sultan Syarif Qasim II International Airport, Pekanbaru, Riau, Indonesia
Fatalities=0
Injuries=1
Aircraft Type=Boeing 737-200
Operator=Lion Air
Tail Number=
Passengers=96
Crew=7
Survivors=103

Lion Air Flight JT-386 was a Boeing 737-200 airliner that crashed on take-off at Sultan Syarif Kasim II Airport, Pekanbaru, Riau, Indonesia, while heading for Batam. The crash occurred at 10.15am local time on January 14, 2002. All passengers and crew survived.

The crash

Onboard the aircraft (registration PK-LID) were 96 passengers and seven crew. The weather was good, and the aircraft was within normal operation weights.

The flight crew correctly set their flight speeds then attempted to take take-off. At rotation speed the First Officer (FO), who was flying the aircraft, pulled back on the control column and lifted the nose up to 18 degrees. However the aeroplane did not become airborne. The FO first increased engine power but, when it was clear that the airliner was not going to leave the ground, elected to abort the take-off by selecting full reverse thrust and applying maximum brake. The aircraft overshot the end of the runway, was successfully steered around the landing approach lights, and eventually came to rest 240m beyond the runway.

Both engines had been torn from the wings and the landing gear had collapsed. The right-hand engine was found 50m away, while the left-hand engine had become wedged under the main landing gear bay. The outboard part of the right wing had broken off after hitting a fence, and was leaking fuel. However, there was no fire. The underside of the tail cone showed scratches consisent with having been dragged along the runway due to a high aircraft pitch. The fin was cut off the aircraft shortly after the crash in order not to obstruct landing aircraft's view of the landing lights.

Inside the aircraft the left front door had opened itself when the aircraft's nose had come down hard from the 18 degrees pitch up position. Two trolleys also became free of their safety restraints and blocked the cockpit door.

When the aircraft came to rest the head flight attendant looked through the open front left door but saw that it was blocked by trees. Through the right front door the fourth flight attendant saw smoke, and decided to keep that door closed. The head flight attendant then used a megaphone to ask the passengers to keep calm and evacuate through the over-wing emergency exits.

In the rear of the aircraft the third flight attendant fell from her seat when the aeroplane stopped. The second flight attendant, with her, checked the left rear door but saw that it was too high from the ground. The second flight attendant asked the third to block this door and prevent anyone leaving through it, however a man pushed her aside and leapt from it anyway. The rear right door was 2m from the ground and the third attendant deemed it usable, but the emergency slide failed to inflate. Instead, the attendant allowed people to jump from the door to the ground. In the process, a woman broke her leg – the only serious injury sustained in the incident.

Analysis and conclusions

The accident was investigated by Indonesia's National Transportation Safety Committee.

Both the flight data recorder (FDR) and the cockpit voice recorder (CVR) were recovered, and were sent to the UK's Air Accident Investigation Branch's Farnborough laboratory for analysis. The aircraft was thoroughly examined at the scene, and parts of the flaps system was analysed by Boeing in the United States.

The information from the FDR was consistent with a take-off having been attempted with the flaps stowed, which meant that the lift-off speed was too high to be reached on the runway. It was apparent from inspections that the flap system was functioning normally, except for a faulty circuit breaker in the aural flap warning system.

One track - the cockpit area microphone - was not recorded on the CVR, likely a faulty microphone. The accident investigators came to the conclusion that the flight crew had not followed the pre-flight check list properly, and had failed to set the flaps to their take-off position. The circuit breaker for the flaps warning system had failed before and had not been properly repaired.

What the first flight attendant had thought to be smoke was actually dust thrown up by the impact, and therefore the right front door could have been used in the evacuation. The inflatable slides were later tampered with to make it look as though they had deployed, and so the reason for their failure to inflate could not be determined. However, there were no record that the maintenance the slides required had been carried out.

ee also

*Lion Air Flight 538

References

* [http://www.dephub.go.id/NTSC_Website/NTSC_Website/website/ntsc_aviation/baru/11.PK-LID%20140102_Final%20Report.pdf Accident investigation report (pdf)]