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29.10.2018/ 06:33 LT
Indonesia/ near Kerawang
According to
Indonesian NTSB Preliminary report and other sources:
On 28 October 2018, a Boeing 737-8 (MAX)
aircraft registered PK-LQP was being operated by PT.
Lion Mentari Airlines (Lion Air) as a scheduled
passenger flight from I Gusti Ngurah Rai International Airport (WADD),
Denpasar to Jakarta as LNI043. During pre-flight check, the PIC
discussed with the engineer of the maintenance actions that had been
performed including replacement of the AoA (Angle of Attack)
sensor and had been tested accordingly.
The aircraft departed at 1420 UTC (2220 LT) at night time, the DFDR
showed the stick shaker activated during the rotation and remained
active throughout the flight. About 400 feet, the PIC (Pilot in Command)
noticed on the PFD (Primary Flight Display) the IAS DISAGREE warning
appeared. The PIC handed over control to the SIC and cross checked the
PFDs with the standby instrument and determined that the left PFD had
the problem. The PIC noticed the aircraft was automatically trimming AND
(Aircraft Nose Down). The PIC moved the STAB TRIM switches to CUT OUT
and the SIC (Second in Command) continued the flight with manual trim
without auto-pilot until the end of the flight.
The PIC declared “PAN PAN” to the Denpasar Approach controller due to
instrument failure and requested to maintain runway heading. The PIC
performed three Non-Normal Checklists and none contained the instruction
“Plan to land at the nearest suitable airport”.
The remainder of the flight was uneventful and the aircraft landed
Jakarta about 1556 UTC. After parking, the PIC informed the engineer
about the aircraft problem and entered IAS and ALT Disagree and FEEL
DIFF PRESS problem on the AFML.
The engineer performed flushing the left Pitot Air Data Module (ADM) and
static ADM to rectify the IAS and ALT disagree followed by operation
test on ground and found satisfied. The Feel Differential Pressure was
rectified by performed cleaned electrical connector plug of elevator
feel computer. The test on ground found the problem had been solved.
At 2320 UTC, (0620 on 29 October 2018 LT), the aircraft departed
from Jakarta with intended destination of Pangkal Pinang. The
DFDR (Digital Flight Data Recorder) recorded a difference between left
and right AoA of about 20° and continued until the end of recording.
During rotation the left control column stick shaker activated and
continued for most of the flight.
During the flight the SIC asked the controller to confirm the altitude
of the aircraft and later also asked the speed as shown on the
controller radar display. The SIC reported experienced „flight
control problem‟.
After the flaps retracted, the DFDR recorded automatic AND trim active
followed by flight crew commanded ANU trim. The automatic AND trim
stopped when the flaps extended. When the flaps retracted to 0, the
automatic AND trim and flight crew commanded ANU trim began again and
continued for the remainder of the flight. At 23:31:54 UTC, the DFDR
stopped recording.
The plane went down in waters about 30 meters to
35 meters (98 to 115 ft) deep. On 01 November 2018 the DFDR was
recovered and its data downloaded. In the middle of January 2019 divers
from the Indonesian navy have recovered the second "black box" - the
cockpit voice recorder.
According to the plane's flight data recorder, a
new anti-stall system known as "MCAS" kept automatically pushing the
nose of the plane down. During the aproximatley 13-minute flight, the
pilots fought the downward tilt more than two dozen times until finally
losing control and crashing into the Java Sea at 450 mph.
All 189 people on board were killed.
(List of crew and passengers)
Aeronautical engineer Peter Lemme reviewed the data from the
investigator's preliminary report.
"This is a situation where they're flying the plane manually, they don't
expect this kind of motion, so that definitely threw them off," he said.
Investigators believe a faulty sensor on the outside of the aircraft
caused the MCAS system to malfunction. They also found the plane
experienced incorrect readings on its three previous flights.
The sensor was replaced, but the problem continued.
The pilots made attempts to regain control of the aircraft, but
investigators said they did not hit two cutoff switches that would have
deactivated the automated system - as was done by pilots on the plane's
previous flight.
An erroneous angle-of-attack reading while pilots are flying manually
can cause the plane’s flight computers to command the Max models to
dive, Boeing said in the bulletin to airlines. While planes like the Max
fly mostly on autopilot, pilots can fly manually if they’re dealing with
unusual situations like the malfunctions that occurred on the Lion Air
flight. Pilots can override the nose-down movement by pushing a switch
on their control yoke, but the plane’s computers will resume trying to
dive as soon as they release the switch, the manufacturer said.
Pilots should follow a separate procedure to halt the potentially
dangerous action by the plane, the bulletin said. Flight crews are
taught to handle “uncommanded nose-down stabilizer trim” by memorizing a
procedure to disengage the angle-of-attack inputs to the plane’s
computer system.
That angle-of-attack sensor is intended to measure the direction of air
flow over wings so that they maintain lift. If the flow is disrupted by
a plane going too slow or climbing too steeply, that can cause an
aerodynamic stall and a plane will plummet. However, if the sensor
malfunctions, it can cause the plane’s computers to erroneously think it
is in a stall - which can then command the aircraft to abruptly dive.
The investigation involved the NTSB of the
United States of America as State of design and State of manufacturer,
the TSIB of Singapore and the ATSB of Australia as State provide
assistant that assigned accredited representatives according to ICAO
Annex 13.
History of the Flight
On 29 October 2018, a Boeing 737-8 (MAX) aircraft
registered PK-LQP was being operated by PT. Lion
Mentari Airlines (Lion Air) as a scheduled passenger flight from
Soekarno-Hatta International Airport (WIII), Jakarta1 with intended
destination of Depati Amir Airport (WIPK), Pangkal Pinang2. The
scheduled time of departure from Jakarta was 0545 LT (2245 UTC3 on 28
October 2018) as LNI610.
At 2320 UTC, the aircraft departed from Jakarta using runway 25L and
intended cruising altitude was 27,000 feet. The LNI610 pilot was
instructed to follow the Standard Instrument Departure (SID) of ABASA
1C4.
According to the weight and balance sheet, on board the aircraft were
two pilots, five flight attendants and 181 passengers consisted of 178
adult, one child and two infants. The voyage report5 showed that the
number of flight attendant on board was six flight attendants.
The Digital Flight Data Recorder (DFDR) recorded a difference between
left and right Angle of Attack (AoA)6 of about 20° and continued until
the end of recording. During rotation the left control column stick
shaker7 activated and continued for most of the flight.
Shortly after departure, the Jakarta Tower controller instructed LNI610
to contact Terminal East (TE) controller. At 23:21:22 UTC, the LNI60 SIC
made initial contact with the TE controller who responded that the
aircraft was identified on the controller Aircraft Situational
Display/ASD (radar display). Thereafter, the TE controller instructed
the LNI610 to climb to altitude 27,000 feet.
At 23:21:28 UTC, the LNI610 SIC asked the TE controller to confirm the
altitude of the aircraft as shown on the TE controller radar display.
The TE controller responded that the aircraft altitude was 900 feet and
was acknowledged by the LNI610 Second in Command (SIC).
At 23:21:53 UTC, the LNI610 SIC requested approval to the TE controller
“to some holding point”. The TE controller asked the LNI610 the problem
of the aircraft and the pilot responded “flight control problem”.
The LNI610 descended from altitude 1,700 to 1,600 feet and the TE
controller then asked the LNI610 of the intended altitude. The LNI610
SIC advised the TE controller that the intended altitude was 5,000 feet.
At 23:22:05 UTC, the DFDR recorded the aircraft altitude was
approximately 2,150 feet and the flaps were retracted. After the flaps
reached 0, the DFDR recorded automatic aircraft nose down (AND) trim
active for 10 seconds followed by flight crew commanded aircraft nose up
(ANU) trim.
At 23:22:31 UTC, the TE controller instructed the LNI610 to climb and
maintain altitude of 5,000 feet and to turn left heading 050°. The
instruction was acknowledged by the LNI610 SIC.
At 23:22:48 UTC, the flaps extended to 5 and the automatic AND trim
stopped.
At 23:22:56 UTC, the LNI610 SIC asked the TE controller the speed as
indicated on the radar display. The TE controller responded to the
LNI610 that the ground speed of the aircraft shown on the radar display
was 322 knots.
At 23:24:51 UTC, the TE controller added “FLIGHT CONT TROB” text for
LNI610 target label on the controller radar system as reminder that the
flight was experiencing flight control problem.
At 23:25:05 UTC, the TE controller instructed the LNI610 to turn left
heading 350° and maintain altitude of 5,000 feet. The instruction was
acknowledged by the LNI610 SIC.
At 23:25:18 UTC, the flaps retracted to 0. At 23:25:27 UTC, the
automatic AND trim and flight crew commanded ANU trim recorded began
again and continued for the remainder of the flight.
At 23:26:32 UTC, the TE controller instructed the LNI610 to turn right
heading 050° and maintain altitude of 5,000 feet. The instruction was
acknowledged by the LNI610 SIC.
At 23:26:59 UTC, the TE controller instructed the LNI610 to turn right
heading 070° to avoid traffic. The LNI610 pilot did not respond to the
TE controller‟s instruction, thereafter, the controller called the
LNI610 twice who responded at 23:27:13 UTC.
At 23:27:15 UTC, the TE controller instructed the LNI610 to turn right
heading 090° which was acknowledged by the LNI610 SIC. A few second
later, the TE controller revised the instruction to stop the turn and
fly heading 070° which was acknowledged by the LNI610 SIC.
At 23:28:15 UTC, the TE controller provided traffic information to the
LNI610 who responded “ZERO”. About 14 seconds later, the TE controller
instructed the LNI610 to turn left heading 050° and maintain an altitude
of 5,000 feet. The instruction was acknowledged by the LNI610 SIC.
At 23:29:37 UTC, the TE controller questioned the LNI610 whether the
aircraft was descending as the TE controller noticed that the aircraft
was descending. The LNI610 SIC advised the TE controller that they had a
flight control problem and were flying the aircraft manually.
At 23:29:45 UTC, the TE controller instructed the LNI610 to maintain
heading 050° and contact the Arrival (ARR) controller. The instruction
was acknowledged by the LNI610 SIC.
At 23:30:03 UTC, the LNI610 contacted the ARR
controller and advised that they were experiencing a flight control
problem. The ARR controller advised LNI610 to prepare for landing on
runway 25L and instructed them to fly heading 070°. The instruction was
read back by the LNI610 SIC.
At 23:30:58 UTC, the LNI610 SIC stated “LNI650 due to weather request
proceed to ESALA8” which was approved by the ARR controller.
At 23:31:09 UTC, the LNI610 PIC advised the ARR controller that the
altitude of the aircraft could not be determined due to all aircraft
instruments indicating different altitudes. The pilot used the call sign
of LNI650 during the communication. The ARR controller acknowledged then
stated “LNI610 no restriction”.
At 23:31:23 UTC, the LNI610 PIC requested the ARR controller to block
altitude 3,000 feet above and below for traffic avoidance. The ARR
controller asked what altitude the pilot wanted. At 23:31:35 UTC, the
LNI610 PIC responded “five thou”. The ARR controller approved the pilot
request.
At 23:31:54 UTC, the FDR stopped recording.
The ARR controller attempted to contact LNI610 twice with no response.
At 23:32:19 UTC, the LNI610 target disappeared from the ASD
and changed to flight plan track. The ARR controller and TE controller
attempted to contact LNI610 four more times with no response.
The ARR controller then checked the last known coordinates of LNI610 and
instructed the assistant to report the occurrence to the operations
manager.
The ARR controller requested several aircraft to hold over the last
known position of LNI610 and to conduct a visual search of the area.
About 0005 UTC (0705 LT), tug boat personnel found floating debris at
5°48'56.04"S; 107° 7'23.04"E which was about 33 Nm from Jakarta on
bearing 56°. The debris was later identified as LNI610.
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 Разбившийся
у берегов Индонезии Boeing 737 был новым, погибли 189 человек
 29.10.2018/ 06:33 LT
Индонезия/ Керауанг
Рейс JT610 индонезийского лоукостера Lion Air,
летевший из Джакарты на остров Банка, упал в море спустя 13 минут после
взлета.
На борту находились
189 пассажиров и членов экипажа.
Россиян на борту самолета не было.
Командиром лайнера был Бхавье Сунейя, за плечами которого шесть тысяч
часов налета.
Как же следовало из списка пассажиров, появившихся в сети,
на борту воздушного судна в момент ЧП находился 181 пассажир, в том
числе трое детей, а также восемь членов экипажа - два пилота, пять
бортпроводника и один механик. Никто не
выжил.
Обломки самолета Boeing 737-8 MAX (PK-LQP) водолазы
искали на глубине в 30-35 метров. Упавший Боинг был новым. Такой тип
самолета начал поступать заказчикам в мае 2017 года и компания Lion Air
была в числе первых покупателей нового типа лайнеров.
В районе крушения водолазы обнаружили тела погибших при крушении
пассажирского Boeing в Индонезии.
Власти Индонезии заявили, что командир самолета авиакомпании Lion Air
запросил посадку сразу после взлета. После же этого связь с экипажем
прервалась, лайнер исчез с экранов радаров.
Также Lion Air заверили, что рухнувший Boeing 737-800 был признан
исправным.
Известно, что самолет имел техническую неисправность в системе MCAS.
Указывается, что погрешность была решена в соответствии с процедурой.
О неисправности
стало известно после предыдущего полета самолета из Денпасара в
Ценкаренг (Джакарта).
Президент Индонезии Джоко Видодо, выступая на пресс-конференции на
острове Бали распорядился провести всестороннее расследование причин
крушения пассажирского Boeing 737 авиакомпании Lion Air.
31 октября сообщалось, что спасателям удалось найти фюзеляж лайнера,
затонувшего в Яванском море. Для поисков самописцев были задействованы
гидроакустические приборы. Спасатели подняли на поверхность бортовой
самописец данных полета. Специалистам предстоит расшифровать запись на
нем. Работающие на месте крушения „Боинга” в Индонезии водолазы
обнаружили на глубине 32 метров черный ящик и подняли его на
поверхность.
В середине января 2019 г. доставили и звуковой самописец. Расследование
причин крушения продолжает.
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 Пътнически
самолет се разби в Индонезия, 189 са загинали
29.10.2018/ 06:33 LT
Индонезия/ Керауанг
Пътнически самолет на авиокомпанията "Лайън Еър" изпълнаващ полет
JT610 се разби в Индонезия. На борда е имало
189 души, от които 181
пътници и 8 души екипаж. Двама са чужденци – пилотът
Бхавье Сунейя е индиец, а
един от пасажерите е италианец - Андреа Манфреди (26-годишен).
Няма оцелели. Машината е
паднала в морето близо до остров Ява и е потънала на 15 км северно от
брега на острова. Метеорологичните условия са били добри и не са
затруднявали полета.
Боинг 737 Макс 8 с регистрационни знаци PK-LQP
излита от столицата Джакарта в 6.20 м. вр. за редовен едночасов полет до
град Пангкал Пинанг на остров Суматра. 13 минути по-късно контактът с
екипажа е изгубен, а самолетът пада в морето до бреговете на остров Ява.
Преди машината да изчезне от радарите, пилотите поискали да се върнат
обратно.
Във водата са намерени отломки, за които се смята, че са от изчезналия
самолет, както лични вещи и човешки тела, за които тече процедура за
индентифицирането им. На 01 ноември е открит и доставен на разследващите
бордовият самописец за данните на полета, а в средата на януари 2019
година - гласовият. Националното бюро за разследване на авиационни
събития на Индонезия вече излезе с предварителен доклад, от който става
ясно, че неизправен сензор за ъгъла на атаката на крилото при полет към
системата MCAS, грижеща се самолетът да не загуби скорост и се срине, се
явява причина за трагедията.
При такъв отказ, компютрите свързани със ситемата за управление започват
да натискат носа на самолета надолу и го въвеждат в пикиране дори при
преминаване в режим на ръчно управление. Това обърква и опитни екипажи.
За да се справят със ситуацията е необходимо да изключат самата система
MCAS чрез двете ключета за нея като ги поставят в положение „cutoff”, но
дори тогава, доколкото разбрахме, ще трябва да разполагат поне с
десетина секунди, докато компютрите отреагират на промяната.
По време на полета на предишната смяна на 28
октомври от Денпасар за Джакарта проблемът се е появил в кабината, но
екипажът бил подпомогнат от друг летец, не на смяна, който успял
своевременно да определи проблема, изключили MCAS и оцелели. Последвал
ремонт. Разследването продължава.
Капитанът и вторият пилот са имали общо 11 000 летателни часа. Самолетът
е бил в експлоатация само от няколко месеца. Доставен е на компанията в
средата на август 2018. Нискотарифната "Лайън еър" има над 600 полета
дневно - международни и вътрешни между летищата на индонезийския
архипелаг с неговите над 17 000 острова.
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