Lion Air Flight 610

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Lion Air Flight 610
Picture of the aircraft
PK-LQP, the aircraft involved in the accident, photographed in September 2018
Accident
Date29 October 2018 (2018-10-29)
SummaryCrashed shortly after take-off; under investigation
SiteJava Sea, off the north coast of Karawang Regency, Indonesia
5°46′15″S 107°07′16″E / 5.77083°S 107.12111°E / -5.77083; 107.12111Coordinates: 5°46′15″S 107°07′16″E / 5.77083°S 107.12111°E / -5.77083; 107.12111
Aircraft
Aircraft typeBoeing 737 MAX 8
OperatorLion Air
IATA flight No.JT610
ICAO flight No.LNI610
Call signLION INTER 610
RegistrationPK-LQP
Flight originSoekarno–Hatta International Airport
Jakarta, Indonesia
DestinationDepati Amir Airport
Pangkal Pinang, Indonesia
Passengers181
Crew8
Fatalities189 (all)[1]
Survivors0
Lion Air Flight 610's flight route

Lion Air Flight 610 was a scheduled domestic flight operated by the Indonesian airline Lion Air from Soekarno–Hatta International Airport in Jakarta to Depati Amir Airport in Pangkal Pinang that crashed 13 minutes after takeoff on 29 October 2018.[2][3] Wreckage from the Boeing 737 MAX 8 aircraft was found in the Java Sea, off the coast of Java.[4] All 189 passengers and crew were killed in the accident.[5]

The aircraft had been in service for two months and flown 800 hours; this was the first major accident involving the 737 MAX and the deadliest involving a 737 aircraft. It's also the worst accident involving the company in 18 years history, surpassing the previous crash in Solo that killed 25. A preliminary investigation revealed problems noticed by passengers and crew on the aircraft's previous flight, as well as signs of instrument failure on previous flights. As a result, Boeing issued a warning to all operators of the 737 MAX series to avoid causing an abrupt dive similar to the Lion Air flight.

A search and rescue operation was deployed by the Indonesian government within hours of the aircraft's disappearance and debris were located early in the morning. Human remains were recovered from a 150-nautical-mile (280 km) wide area and the first victim was identified two days after the crash. The flight data recorder was located on 1 November and recovered for analysis. One member of the volunteer rescue team died during recovery operations.

Aircraft[edit]

The aircraft involved was a Boeing 737 MAX 8, registration PK-LQP, line number 7058, powered by two CFM International LEAP engines.[6] The aircraft was leased from CMIG Aviation Capital and delivered new to Lion Air on 13 August 2018.[7][8] At the time of the accident, the aircraft had flown about 800 hours in service.[9] This was the first accident involving a 737 MAX since the type's entry into service on 22 May 2017,[10] and the deadliest accident involving a Boeing 737.[11]

Flight details and accident[edit]

The aircraft took off from Jakarta on 29 October 2018 at 6:20 a.m. local time (28 October 2018, 11:20 p.m. UTC) and was scheduled to arrive at Depati Amir Airport in Pangkal Pinang at 7:20 a.m.[12] It took off in a westward direction before circling around to a northeasterly heading, which it held until crashing offshore northeast of Jakarta in waters estimated to be up to 35 metres (115 ft) deep.[13][14] According to an official at Pangkal Pinang's search and rescue office, the flight crew had requested clearance to return to the Jakarta airport 19 nautical miles (22 mi; 35 km) into the flight.[15][16] The accident site was located 34 kilometres (21 mi; 18 nmi) off the coast of the island of Java.[17]

Communication between air traffic control (ATC) and Flight 610 was abruptly lost at 06:33 a.m.[18] ATC immediately informed authorities about the incident and the Indonesian National Search and Rescue Agency deployed three ships and a helicopter to the area.[19] At 07:30 a.m., the agency received reports that Flight 610 had crashed a few kilometres from an offshore oil platform.[20] Workers on the platform reportedly saw the aircraft crash with a steep nose-down angle.[21] Boats from the platform were immediately deployed and debris from the crashed aircraft was found shortly after.[22]

Map showing flightpath of Lion Air Flight 610

Passengers and crew[edit]

According to Indonesian officials, there were 189 people on board the aircraft: 181 passengers (178 adults, 1 child and 2 infants), as well as six cabin crew and two pilots.[23] Officials confirmed that all 189 passengers and crew on board had been killed.[24]

Crew[edit]

Lion Air identified the flight's captain as an Indian national, who had flown with the airline for more than seven years and had logged about 6,000 hours of flight time; and the co-pilot as an Indonesian who had logged about 5,000 hours of flight time. The six flight attendants were also Indonesian.[25]

Passengers[edit]

Twenty Ministry of Finance employees,[14] 10 Audit Board of Indonesia employees,[26] two auditors from the Finance and Development Inspection Agency [id],[27] three Ministry of Energy and Mineral Resources employees,[28] three public attorneys,[29] three Indonesian National Police officers,[30] six Bangka Belitung Regional People's Representative Council members,[31] and three judges of Indonesia's High Court and National Court.[32] A total of 38 civil servants, three police officers and 10 state officials, were among the passengers. There were two confirmed foreigners among those on board: the pilot from India and an Italian citizen, former professional cyclist Andrea Manfredi.[5][33]

Response[edit]

A search and rescue operation was launched by the Indonesian National Search and Rescue Agency (Basarnas), with assistance from the Indonesian Air Force[34] the Indonesian Navy[35] , and the Singaporean Navy. Basarnas dispatched about 150 people in boats and helicopters to the site of the accident.[13] Civilian vessels also responded to the reports of a downed aircraft, and the crew of a tugboat reported to authorities in Tanjung Priok that they had witnessed an aircraft crash at 6:45 a.m. and located debris in the water at 7:15 a.m.[12][36] The Indonesian Agency for Assessment and Application for Technology deployed the research ship Baruna Jaya, which had been previously deployed during the search for Adam Air Flight 574 and Indonesia AirAsia Flight 8501.[37]

A spokesperson for the agency confirmed to reporters that the aircraft had crashed,[36] though as of about 9:00 a.m. a Tanjung Priok official said that no information had emerged about the condition of the people on board.[38] Muhammad Syaugi, head of Basarnas, later confirmed that there had been casualties, without specifying a number.[13]

Indonesian Minister of Transportation Budi Karya Sumadi giving a press conference on the crash of Flight 610

In response to the crash, the Indonesian Transportation Ministry set up crisis centres in Jakarta[39] and Pangkal Pinang.[40][41] Lion Air also offered free flights for the families of the victims to Jakarta. On 30 October, more than 90 relatives were flown to Jakarta for the identification of the victims.[42] CEO of Lion Air Edward Sirait stated that accommodation had been provided for the relatives, and later added that relatives should go to Halim Perdanakusuma International Airport for further information.[43] The Indonesian National Police announced that trauma healing team would be provided for the relatives of the victims.[44]

Indonesia's People's Representative Council announced on 29 October that they would examine the Standard Operating Procedure of Lion Air and the airworthiness of the aircraft. They would also examine the health history of the crew of Flight 610.[45] The Head of the People's Representative Council, Bambang Soesatyo, later asked the government to enforce stricter rules for the aviation industry and to audit every airliner in the country.[46] On 1 November, Indonesian Minister of Transportation Budi Karya Sumadi announced that the government would evaluate every low-cost carrier in Indonesia.[47]

As 20 of the passengers were employees of the Indonesian Ministry of Finance, Sri Mulyani, the Indonesian Finance Minister immediately visited the Indonesian Search and Rescue Agency's office in Jakarta, seeking coordination and further information.[48] She later announced that every employee of her ministry should wear a black ribbon for a week to commemorate the victims.[49] Posthumous awards would be given to the 20 victims and scholarship would be given to the victims' children.[50]

Minister of Health Nila F Moeloek[51] and Minister of Transportation Budi Karya Sumadi visited the relatives of the victims. Indonesian President Joko Widodo, who was attending a conference in Bali during the crash,[52] visited the recovery efforts at the Port of Tanjung Priok the next day.[53]

The Australian Department of Foreign Affairs and Trade announced that its staff would be banned from flying on Lion Air, as well as its subsidiary airlines Batik Air and Wings Air, until the cause of the accident was known.[54] The Indonesian Minister of Transportation, Budi Karya Sumadi, later stated that his ministry would hold talks with the Australian government about the warning.[55][56]

The government-owned social insurance company Jasa Raharja announced that the victims' families would each receive 50 million rupiah (US$3737) in compensation.[57]

In the immediate aftermath of the crash, the Indonesian media were warned by Indonesian Broadcasting Commission for their unethical coverage of the crash. Some media were accused of pushing the family members to answer unethical questions.[58] Chairman of Indonesia's Alliance of Independent Journalists (AJI), Abdul Manan, stated that images of debris were broadcast repeatedly and inappropriately. This, in turn, traumatized relatives of the victims. In response, some Indonesians voiced their anger and disappointment on social media.[59]

On 31 October, Transportation Minister Budi Karya Sumadi temporarily suspended Lion Air's technical director Muhammad Arif from his duties based on the crash investigation. Budi said the ministry had also suspended an unspecified number of Lion Air technicians who had cleared the aircraft for its final flight.[60]

Recovery operations[edit]

Officials from the Indonesian National Search and Rescue Agency announced that the search and rescue operation would be conducted for seven days and be extended by three days if needed. A command centre was set up in Tanjung Priok.[61]

On 29 October, authorities said that all on board were presumed dead and that the first human remains had been recovered.[62] Divers had located fragments of the aircraft's fuselage and assorted debris, but had yet to find the onboard flight recorders.[62] An official from the Indonesian National Armed Forces predicted that most of the victims were still inside the fuselage, as in the days following the crash, rescue personnel only managed to recover a small number of body parts.[63] Officials stated that bad visibility and strong sea current hampered the search and rescue effort.[64]

On the same day, the Indonesian National Search and Rescue Agency published the area of the search and rescue operation. It was divided into two main area. The first was a 62 nautical miles (115 km; 71 mi)[clarification needed] underwater search area while the second was a "visual search" area, 124 nautical miles (230 km; 143 mi) wide.[65]

On 30 October, the search area was divided into 13 sectors. The search area was widened to 150 nautical miles (280 km; 170 mi),[clarification needed][66] reaching as far as Indramayu to the east. Approximately 850 personnel from the Indonesian National Search and Rescue Agency, Indonesian National Armed Forces and volunteers participated in the operation.[67] At least 13 bodies were retrieved from the crash site.[68] Indonesian officials confirmed that faint pings had been heard in the search area.[69]

On 31 October, it was reported that acoustic "pings" had been detected, no further than 3 kilometres (1.9 mi) from the group of eight current search points, which were possibly from one or both of the underwater locator beacons (ULBs) attached to the aircraft's flight recorders.[70]

The first victim was identified on 31 October.[71] At the time, more than a dozen body parts had been found by authorities. Some of the parts had drifted more than 5 kilometres (3.1 mi) in the sea current. Police also reported that 152 DNA samples had been collected from the victims' relatives.[71] Hundreds of pieces of the aircraft had also been recovered; all of them were transported to Tanjung Priok, Jakarta.[72] Authorities stated that the search area for dead bodies and debris would be focused in the sea off Karawang Regency, a coastal area of Java close to the crash site, as analysis showed that the sea currents in the area would bring debris to the south. A command centre was set up in Tanjung Pakis, Karawang to oversee the salvage effort.[72]

On the same day, authorities widened the search area from 10 nautical miles (19 km; 12 mi) to 15 nautical miles (28 km; 17 mi). In all, 39 ships (including 4 equipped with sonar) and 50 divers were deployed to the search area.[73] The Indonesian National Police announced that 651 personnel had joined and assisted in the search and rescue operation.[74] Officials stated that the operation, starting from 31 October, would focus on finding the fuselage of the aircraft and the flight recorders.[75]

The joint search and rescue team announced on 31 October that at least three objects, one of which was suspected to be one of the aircraft's wings, were found in the search area.[76] Officials confirmed that "pings" from the aircraft's ULBs were also heard near the area.[77]

On 1 November, searchers announced that they had found Flight 610's flight data recorder (FDR), which was located at a depth of 32 metres (105 ft). The cockpit voice recorder (CVR), however, was reported as not yet found.[78] According to a transport safety official, quoted by Reuters news agency, authorities did not initially know for certain whether the "crash survivable memory unit" was from the flight data recorder or cockpit voice recorder, as portions of it were missing.[79] Haryo Satmiko, deputy chief of Indonesia's National Transportation Safety Committee (NTSC), the body investigating the crash, told journalists that the device's poor condition was evidence of the "extraordinary impact" of the crash, which had separated the memory unit from its housing.[80][81] Despite the damage, investigators were able to recover data from the aircraft's previous 19 flights spanning 69 hours, and planned to begin analysis on 5 November.[81]

On 2 November, the joint search and rescue team deployed more than 850 personnel and 45 vessels to the crash site. The aerial search area was widened to 190 nautical miles (350 km; 220 mi) and the "underwater search area" was widened to 270 nautical miles (500 km; 310 mi).[82] Joint search and rescue team announced that some engine parts were found in the search area.[83] One of the aircraft's landing gears was recovered on the afternoon.[84] Meanwhile, the Disaster Victim Identification team stated that at least 250 body parts had been recovered from the crash site.[85]

On 3 November, it was reported that a volunteer Indonesian rescue diver had died during the search, on the afternoon of 2 November.[86] It is believed he died from decompression.[87]

A second landing gear and both of the aircraft's engines were able to be recovered by search and rescue personnel, while the main body of the aircraft had been located by authorities. The main wreckage of the aircraft was located 7.5 miles (12.1 km)[clarification needed] from the coast of Tanjung Pakis and was located around 200 metres (220 yd) from the location where the FDR was discovered. Divers were immediately dispatched to the area. Faint "pings" from the ULB attached to the aircraft's CVR were also heard.[88][89][90][91]

On 4 November, nearly 1,400 personnel, including 175 divers, were dispatched to the crash site. 69 ships, 5 helicopters and 30 ambulances were also dispatched. [92] The Head of the Indonesian National Search and Rescue Agency Muhammad Syaugi announced that the search and rescue operation would be extended for another three days.[93]

Investigation[edit]

The aircraft was used on a flight from Ngurah Rai International Airport, Bali to Soekarno-Hatta International Airport, Jakarta the night before the crash. Passengers on that flight recounted that the aircraft had suffered an engine problem and were told not to board it as engineers tried to fix the problem. While the aircraft was en-route to Jakarta, it had problems maintaining a constant altitude, with passengers stating that it was like "a roller-coaster ride".[94] The chief executive officer of Lion Air, Edward Sirait, said the aircraft had a "technical issue" on Sunday night, but this had been addressed in accordance with maintenance manuals issued by the manufacturer. Engineers had declared that the aircraft was ready for takeoff on the morning of the accident.[95][96]

On 30 October, Indonesia's Transportation Ministry ordered all of the country's airlines to conduct emergency inspections on their 737 MAX 8 aircraft. The ministry would also launch a special audit on Lion Air to see if there were any problems with its management system.[97] The Transportation Ministry announced that all of the Boeing 737 MAX 8 aircraft are airworthy and are allowed to return to normal operation.[98]

The Indonesian Meteorology, Climatology, and Geophysical Agency (BMKG) reported that the weather was clear around the time of the crash, with winds at 5 knots (9.3 km/h; 5.8 mph) from the northwest. Visibility was good with no cumulonimbus clouds.[99]

A Boeing technician and engineer, and a team from the US National Transportation Safety Board arrived on 31 October to help with the investigation being conducted by the NTSC. Personnel from the US Federal Aviation Administration (FAA) and engine manufacturer GE Aviation were also sent to Indonesia. A team from Singapore, that had already arrived on the night of 29 October, was to provide assistance in recovering the aircraft's flight recorders. The Australian Transport Safety Bureau sent two of its personnel to assist with the downloading process of the FDR.[100]

Aviation experts noted that there were some abnormalities in the altitude and the airspeed of Flight 610. Just three minutes into the flight, the captain asked the controller for permission to return to the airport as there were flight control problems.[101] About eight minutes into the flight, data transmitted automatically by the aircraft showed it had descended to about 5,000 feet (1,500 m) but its altitude continued to fluctuate. The mean value of the airspeed data transmitted by Flight 610 was around 300 knots (560 km/h; 350 mph), which was considered by experts to be unusual, as typically aircraft at altitudes lower than 10,000 feet (3,000 m) are restricted to an airspeed of 250 knots (460 km/h; 290 mph). Ten minutes into the flight, the data recorded the aircraft dropping by more than 3,000 feet (910 m). The last recorded altitude of the aircraft was 2,500 feet (760 m).[102][103]

A number of news sources, including The New York Times and The Daily Telegraph, reported the speculation of Indonesian aviation expert Gerry Soejatman that the pitot tubes, used in the airspeed indication system, may have played a role in the crash; they have contributed to similar crashes previously.[104][105]

Police Hospital Chief Musyafak said that an examination of the body parts indicated that it was unlikely that there had been an explosion or fire on board the aircraft.[106]

Detailed reports regarding the aircraft's last flight prior to Flight 610 (from Denpasar to Jakarta), revealed that the aircraft had suffered a serious incident. Passengers in the cabin reported heavy shaking and a smell of burnt rubber inside the cabin. At one point, the aircraft had dropped more than 200 feet (61 m) in a few seconds. Many of the passengers were left traumatized by the incident.[107] The seat belt sign was never turned off from take off to landing. A recording of air traffic control communications indicated that the pilot had called a "pan-pan",[108] the second highest alert level after a Mayday call. However, the crew later decided to cancel the pan-pan and continue the flight to Jakarta.[109] The aircraft's maintenance logbook revealed that during that flight, the aircraft suffered an unspecified navigation failure on the Captain's side, while the First Officer's side was reported to be in good condition.[110]

On 5 November, the NTSC announced that Flight 610 was still intact when it crashed into the sea and struck at high speed, citing the relatively small size of the pieces of debris. The impact was so powerful that the strongest part of the aircraft was obliterated.[111] The NTSC also stated that the engines of Flight 610 were still running when it impacted the sea,[112] indicated by the high RPM. Further examination on the aircraft's instruments revealed that one of the aircraft's airspeed indicators had malfunctioned for its last four flights.[113]

On 7 November, the NTSC confirmed that there had been problems with Flight 610's angle of attack (AoA) sensors. The aircraft suffered an airspeed indicator problem for its last four flights, including the flight to Denpasar. Thinking that it would fix the problem, the engineers in Bali then replaced one of the aircraft's AoA sensors, but the problem persisted on the penultimate flight, from Denpasar to Jakarta. Just minutes after takeoff, the aircraft abruptly dived. The crew of that flight, however, had managed to control the aircraft and decided to fly at a lower than normal altitude. They then managed to land the aircraft safely and recorded a twenty-degree difference between the readings of the left AoA sensor and the right sensor.[114] NTSC chief Soerjanto Tjahjono told the press that future reporting or actions, enacted to prevent similar problems on similar aircraft, would be decided by Boeing and US aviation authorities.[115]

Reaction[edit]

On 6 November, The Wall Street Journal reported that Boeing and the FAA, on the basis of preliminary information gathered in the investigation, were planning to publish warnings, about erroneous angle of attack indications, on cockpit instrument displays of the 737 MAX in response to the Lion Air accident.[116] The report stated that, based on preliminary findings, it is believed a malfunction in the AOA sensors could lead the on-board computer to believe that the aircraft is stalling, causing it to automatically initiate a dive. The Federal Aviation Administration urged all airlines operating Boeing 737 MAX 8s to heed the warnings.[117] In response to the news of the faulty AoA sensor and the operation of the MCAS, the FAA issued an emergency Airworthiness Directive (AD) requiring that amended operating limitations and procedures, relating to erroneous data from an AoA sensor, be inserted into the aircraft flight manual of each 737 MAX aircraft.[118]

During difference training, pilots of American Airlines and Southwest Airlines converting from earlier Boeing 737 Next Generation models to the 737 MAX were not informed of the Maneuvering Characteristics Augmentation System (MCAS) linked to the fatal crash, leaving them concerned that they were possibly untrained with respect to other differences.[119] In November 2018, Aviation Week reviewed the 737 MAX flight crew operations manual and found that it did not mention the MCAS.[120] American Airlines' Allied Pilots Association and Southwest Airlines Pilots' Association were also caught unaware.[121] The Wall Street Journal reported that Boeing had "decided against disclosing more details to cockpit crews due to concerns about inundating average pilots with too much information."[122]

The CFM International LEAP engines of the 737 MAX have a higher bypass ratio and have a larger nacelle than the engines of previous Boeing 737 models, so the engines are placed higher and further forward in relation to the wing than on previous models. This destabilises the aircraft in pitch at higher angles of attack; to deal with this the MCAS flight control augmentation system is fitted to the 737 MAX.[123] Former Boeing engineers expressed the opinion that a nose down command triggered by a sensor single point of failure is a design flaw if the crew is not prepared, and the FAA was evaluating a fix of the possible flaw and investigating if the pilots' transition training is adequate.[124]

On 15 November, the US Air Line Pilots Association (ALPA), the largest union, representing 61,000 pilots, urged the FAA and NTSB to ensure pilots receive all relevant information, addressing a "potential, significant aviation system safety deficiency".[125] ALPA' United Airlines branch, in line with its management, disagrees as the 737 pilot manual includes a standard procedure to shut down the flight-control behavior, and dismissed the MCAS implication in the accident as "speculation" based on the Boeing safety-warning bulletin and the follow-on FAA airworthiness directive.[126]

On 19 November, Boeing CEO Dennis Muilenburg defended in an internal message the Flight Crew Operations Manual as describing the MCAS relevant function.[127] On 20 November, Boeing was to hold a conference call with 737 Max operators to detail the new MCAS not present in the NG.[128]

See also[edit]

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