FSR 49 Final

FLIGHT CREW DIVISION
FLIGHT SAFETY REVIEW

Edition Aug 2018
Issue 49
Edition Aug 2018
FLIGHT SAFETY REVIEW

B787 VN300 SGN-NRT: HIGH RATE OF DESCENT DURING
APPROACH BETWEEN 1000-500FT
B787 VN248 SGN-HAN: FAILED TO FOLLOW TAXI-OUT CLEARANCE
CAUSED OTHER A/C RTO
B787 VN248 SGN-HAN: TAXIED TO THE CLOSED TAXIWAY
B787 VN513 PEK-HAN: FAILED TO FOLLOW TAXI INSTRUCTION
A321 VN7344 SGN-CXR: LANDED ON THE WRONG RUNWAY
A321 VN302 SGN-NRT: FIRM LANDING
A321 VN7810 PQC-SGN: HARD LANDING
A321 VN506 HAN-CAN: FAILED TO FOLLOW TAXI INSTRUCTION
A321 VN1266 SGN-VII: RUNWAY EXCURSION DURING LANDING
A321 VN1544 HUI-HAN: RUNWAY EXCURSION DURING LANDING
ATR72 0V8380 SGN-DLI: HIGH RATE OF DESCENT DURING
APPROACH BETWEEN 1000-500FT
OTHERS INTERNATIONAL ACCIDENT
Issue 49
FLIGHT SAFETY REVIEW Edition Aug 2018
HIGH RATE OF DESCENT DURING APPROACH BETWEEN 1000-500FT
VN300 SGN-NRT 16/05/2018 (B787)
Captain was the PF for ILS 16R in good Wx condition.

A/C was high on profile when LOC is captured.
Crew tried to intercept G/S from above.
Flight violated level 3 of high rate of descent during approach
between 1000ft & 500ft,
Max value recorded was -2055ft/min, limit -1500ft/min
Max value: -2055ft/min

Limit : -1500ft/min
Crew Crew needs to improve flight

management & management and situational
situational awareness.
awareness were Crew must always monitor the
below descent profile and manage to
standards. config the A/C earlier if required.
Crew must follow SOP 2.7.7. Any deviation from
Crew did not perform go-around. stabilized criteria, Go-around must be initiated

Page 03
HIGH RATE OF DESCENT DURING APPROACH BETWEEN 1000-500FT
VN300 SGN-NRT 16/05/2018 (B787)
B787 SOP 2.7.7:
2.7.7 Stabilized Final Approach
This part is based on and comply with Flight Operations Manual (FOM 8.3.1.9)
• For circling to land approach, aircraft wings must be leveled by 300ft AGL.
• For base training flights, aircraft must be stabilized by 500ft AGL.
• For all other flights, aircraft must be stabilized by 1000ft AGL.
For certain reason, if the approach becomes unstabilized below the above mentioned height,
go-around must be initiated immediately.
An approach is stabilized when all of the following criteria are met:
• The aircraft is on the correct flight path;
• Only small changes of heading/pitch are required to maintain the correct flight path;
• The aircraft speed is not more than IAS target (indicated by magenta triangle) +10 kt
and not less than Vapp – 5 kt;
• The aircraft is in the correct landing configuration;
• Rate of descent is no greater than 1000 feet per minute (if an approach requires a
rate of descent greater than 1000 feet per minute a special briefing should be
conducted);
• Power setting is appropriate for the aircraft configuration;
• All briefings and checklists have been completed.
Note: The above criteria must be maintained through the rest of the approach for it to be
considered a stabilized approach.
Note: Manual flying is only to be carried out after the landing checklist has been done and the
flight is stabilized.
The specific types of approaches are stabilized if they also meet the following additional
criteria:
• ILS approaches must be flown within one(1) dot of the glideslope and localizer.
• During circling approach wings must be level on final when the aircraft reaches 300 ft
above the airport elevation.
The above criteria must be maintained through the rest of the approach for it to be considered
a stabilized approach. If the above criteria cannot be established and maintained at and below
500ft above airport elevation an immediate go-around must be initiated.
At 100ft above the airport elevation for all visual approaches the aircraft must be positioned so
that the flight deck is within and tracking so as to remain within the lateral confines of the
runway’s extended center-line.
As the aircraft cross the threshold it must be:
• Stabilized on target airspeed to within 10kt until arresting descent rate at flare.
• On a stabilized flight path using normal manoeuver.
• Positioned to make a normal landing in the touch down zone.
If the above criteria cannot be maintained a go-around shall be initiated.

Page 04
FAILED TO FOLLOW TAXI-OUT CLEARANCE CAUSED OTHER A/C RTO

VN248 SGN-HAN 06/07/2018 (B787)
Occurrences:
A/C was pushed-back from Parking No.8.
Clearance for taxi: NS-NS2-E8-E6- Holding point RWY 25L.
Instead of turning right to E8 from NS2, Crew continued straight in NS2 and crossed
the RWY holding line.
Crew immediately stopped the A/C and informed to ATC the situation.
Flight TR307 had to abort the Take-off due to RWY incursion.

Page 05
FAILED TO FOLLOW TAXI-OUT CLEARANCE CAUSED OTHER A/C RTO

VN248 SGN-HAN 06/07/2018 (B787)
Crew failed to follow Crew needs to
SOP 2.3.2 taxi out and concentrate, do
SOP 2.1 Operation crosscheck during taxi,
policy: Activate- especially when passing
Navigate- Communicate. intersection.
Marking was hard to see PM needs to give proper assist to Captain
due to sunshine and wet RWY. during taxi.
TAXI TO THE CLOSED TAXIWAY

VN248 SGN-HAN 26/07/2018 (B787)
1. Occurrences:
After landing on RWY 11L at Noibai, crew was cleared to vacate via S1-
cross 11R- Continue on S1.
After crossed 11R, crew taxied to S1A instead of S1 (S1A is closed), then
A/C had to towed back to S1 before continue taxi to the gate.

Page 06
TAXI TO THE CLOSED TAXIWAY
VN248 SGN-HAN 26/07/2018 (B787)
Crew failed to Crew needs to concentrate,
follow SOP 2.10 taxi do crosscheck during taxi,
in. especially when passing
Crew did not intersection.
briefing properly, PM needs to give proper
did not crosscheck. assist to Captain during taxi follow SOP 2.10.
FAILED TO COMPLY WITH TAXI CLEARANCE

VN513 PEK-HAN 18/05/2018 (B787)
1. Occurrences:
Crew was cleared to follow Z3 heading north and holding at S4, then S4-F-
and hold at W7.
While A/c approached taxiway F, crew turned left instead of turned right.
Crew then was instructed another route to continue.
Clearance
Crew taxi

Page 07
VN513 PEK-HAN 18/05/2018 (B787)
Crew failed to follow SOP 2.3.2 Taxi out, did not

crosscheck with Terminal chart to confirm with the
Findings clearance.
Crew did not write report after flight.
Pilot who is not taxiing aircraft concentrates

on navigation giving advice on taxi route from
airport chart on EFB (or Ipad as back up),
including surface markings, heading, direction
information, speed and visual cues that are to
be expected.
If there is any doubt about the position or
obstruction clearance, the crew shall stop the
airplane immediately, inform ATC and may
request follow-me car
Crew needs to follow SOP, take note all taxi instruction to CFP,
briefing and crosscheck to make sure the clearance is correctly
acknowledged.
Resolutions
PM needs to monitor, warn the captain about TWY, direction,
Crew must stop the A/C and confirm with ATC if there is any
doubt.

Page 08
LANDED ON THE WRONG RUNWAY

VN7344 SGN-CXR 29/04/2018 (A321)
1. Occurrences:
14:15 LT VN7344 departed VVTS and planned ILS approach RWY 02 at CXR.
14:40 LT VN7344 was transferred to CXR TWR and was instructed for RNAV
approach RWY 20.
14:45 at FL130, crew was cleared for RNAV approach.
14:50 at 1600ft, crew had visual contact with RWY20.
14:52:03 at 1200ft, Heading 196, AP was disconnected for manual flight.
14:53:50 A/C was landed on RWY 20L
14:52:03 LT, 1204ft,

Heading 196°, Crew
disconnected AP
RWY 20 in use
Flight path VN7344
RWY 20L under construction
2. Findings:
Main causes:
In VMC condition, Crew mista kenly believed Rwy 20L which was under
construction as R WY in use 20
Crew didn’t notice that the Papi was not located correctly, as there is no Papi sys for
the new R WY.

Page 09

VN7344 SGN-CXR 29/04/2018 (A321)
2. Findings:
Other factors:
Crew did not receive NOTAM that states the new RWY 20 is under constructed. No
ATIS nor ATC warned about that new construction.
RWY 20L was mostly completed (in markings) that is easy to confuse. RWY 20
from the above was very hard to see compared with RWY 20L.
There was no cross (X) marking for RWY not in use.
Crew did approach and visual landing in sunshine afternoon that made difficult to
see the runway surface
RWY 20 in use
Barrier A/C stop A/CTouch down

Threshold
1000m 500m Marked “20L”
450m
3. Resolutions:
Crew needs to study Airport chart carefully.
RWY under -construction or unserviceable must be mark the cross “X” at RWY
threshold. Extremely Caution information should be provided to crew by NOTAM,
ATIS or TWR controller.
VVCR and VVDN are soon to install ATIS to reduce work load for crew and
controllers.

Page 10

VN7344 SGN-CXR 29/04/2018 (A321)

Page 11
FIRM LANDING
VN302 SGN-NRT 09/04/2018 (A321)
1st approach RWY 16L, crew went around due to gusting wind.
s
2nd approach RWY 16R, A/C was landed with G-load 2.54G.
ce
Captain was PF. The flight violated level 3 of FIRM LANDING,

e n
ur r
Max value 2.54G limit 2.3G.
Oc c
Max value: 2.54G

Max value: -1632ft/min,
Max value: -1632ft/min
Limit -1500ft/min.
Limit : 2.3G
Limit: -1500ft/min
Crew did approach and landing in strong gusting wind condition.

Landing technique under gusting wind condition was not good Findings
enough: late flare, late pitch up input.
Crew needs to improve the landing technique.

Crew needs to review FCTM-PR-NP-SOP- 250 P2/10.

Page 12
HARD LANDING
VN7810 PQC-SGN 18/05/2018 (A321)
Captain was PF
The crew made an ILS approach Rwy 25R in bad weather conditions.
During final, the weather still above the landing minima.
At flare height, the crew experienced heavy rain with sudden falled in
visibility.
Aircraft touched down with G-load recorded 2.71.
The Flight violated level 3 of Hard landing, max value 2.71G, limit 2.6G.
Max value 2.7G

Limit 2.6G
Captain did late flare.

Wx was unpredictable during approach and landing.
The landing technique should be

improved.
The crew should take extra caution during landing and take-
off under bad weather condition.
The crew should consider to reject landing or to hold if the weather become
unfavorable.
Crew needs to follow FOM 8.8.8.2.4.

Page 13
VN506 HAN- CAN 20/05/2018 (A321)
After landing, aircraft vacated on taxi way Y12, ATC cleared

VN506 via Y South-bound and change the frequency.
The Controller noticed that crew missed the taxiway P8
(standard taxi routes for arrival RWY19, 20L) and instructed
VN506 to follow Y, Y15 hold short of RWY20R. Crew read-
back correctly, but then again missed the Y15 taxiway,
continued South bound. ATC asked to hold position and wait for the follow me car.
FIRST
CLEARANCE
2nd
CLEARANCE
3rd CLEARANCE
Due to communication interferences:

1st : crew did not acknowledge the entire taxi instruction from
Findings ATC.
2nd : crew did not study taxi route correctly before continue to
taxi. Crew failed to follow SOP 2.10 taxi in.
Crew must concentrate, do crosscheck during taxi, especially

when passing intersection.
Crew must follow SOP 2.10 taxi-in, FOM 8.3.17.18a, stop the Resolutions
A/C and confirm with ATC if there is doubt.

Page 14
RUNWAY EXCURSION
VN1266 SGN-VII 16/07/2018 (A321)
Occurrences:
Flight VN1266 departed from SGN with good weather and no MEL concerning about
nosewheel.
During the approach weather went below minima: wind 290/4kts, Vis 1500m/ + RA, crew did
3 holding at 7000ft.
Crew decided to continue the approach RWY17 when reported VIS was 6000m.
During short final till touch down wind was 350/11kts. The a/c landed on the left of runway
centerline and continued veering off the runway.
Crew control the aircraft back on Rwy, while attempting to turn around and taxi to the apron
the A/c became disable due to the right nose gear tyre having deflated and the nose wheel turned
90º to the right. Passengers disembarked on the runway.
TAF:
VVVH 160500Z 1606/1706 33009KT 8000 -RA SCT012 BKN040 TEMPO
1606/1613 3000 +RA FEW005 BKN010 FEW020TCU BKN040 TEMPO
1614/1618 5000 RA FEW010 BKN040 TEMPO 1702/17 06 3000 +RA
SCT010 FEW020TCU BKN040=
Estimated approach time at VVVH 12:27Z according to CFP

Page 15
RUNWAY EXCURSION
VN1266 SGN-VII 16/07/2018 (A321)

Page 16
RUNWAY EXCURSION
VN1266 SGN-VII 16/07/2018 (A321)

Page 17
RUNWAY EXCURSION
VN1266 SGN-VII 16/07/2018 (A321)
Findings
Heavy rain, visibility rapidly dropped and wind changed from tailwind to fully
crosswind and increased velocity (350/11kts to 260/26kts) at touchdown caused the
A/c went off the runway .
The A/c have drifted to the left of centerline just before touched down, the Rwy was
wet, slippery and strong cross wind from the right made the crew unable to get back
to centerline.
Crew failed to follow SOP 2.1.9 Task sharing, SOP 1.3.2 tail wind limitation, FOM
8.3.8.2.4 approach and landing in adverse weather.
Crew did not discon nect AP early enough to resume manual control and evaluate t
drift before flare (follow FCTM)
Landing technique under adverse weather condition was below standard (positive
landing, firm landing due to slippery RWY - hydroplaning).
Crew disconnected Autobra ke to manage directional control -increased workload.
ATC did not update Wx condition on time to support pilot during weather
deterioration.
RWY 17 did not have RWY center light, and the centerline was partly covered by
rubber.
All crews must assess carefully the Wx before deciding to

conduct the approach.
Consideration of diversion or delay approach.
All crews should improve landing technique under adverse
Wx, touch down at touch-down zone and on RWY
centerline, positive landing, firm landing in slippery RWY
condition.

Page 18
RUNWAY EXCURSION
VN1544 HUI-HAN 28/07/2018 (A321)
Occurrences:
ILS APP 11L at Noibai, the A/c was stabilized from 1000ft. F/O was PF
According to Capt report: Rain started at 150ft, Wiper was used at maximum and RWY was in-
sight
During flare (3s before touch-down) wind have changed from head-wind to right cross-wind,
increased in velocity, heavy rain, sudden lost of Vis, crew could not see the RWY. A/C have
drifted to the left and left main Gear went off the RWY.
Crew controlled the A/C back to the centerline and taxied to the parking with no further event.
The ground maintenance reported there was grass and dirt on the Landing Gear.

Page 19
RUNWAY EXCURSION
VN1544 HUI-HAN 28/07/2018 (A321)

Page 20
RUNWAY EXCURSION
VN1544 HUI-HAN 28/07/2018 (A321)
Approach and Landing at night time, heavy rain, loss of Visibility,
wind rapidly changed from head wind to right crosswind and gust
up to 22kts, crew did not see the RWY at touch down.
Difficulty to maintain on the Centerline due to wet and slippery
Rwy surface under heavy rain and strong crosswind.
Crew failed to follow SOP 2.1.9 Task sharing, SOP 1.3.2 tail wind
limitation, FOM 8.3.8.2.4 approach and landing in adverse weather.
Landing technique under adverse weather was below standard (positive landing, firm
landing due to slippery RWY- hydroplaning). Captain did not take control timely.
ATC failed to advise and support crew during weather deterioration.
RWY 11L did not have RWY center light, RWY centerline was partly covered by rubber.
All crew members must assess Wx carefully before deciding

to conduct the approach, initiate the miss-approach when Wx
is expected worse.
Consideration of diversion or delay approach.
Captain must be PF in adverse Wx or when the Wx is expecting worse during
approach.
All crews should improve landing technique in adverse Wx, touch down at touch-
down zone and on RWY centerline, positive landing, firm landing in slippery RWY
condition.
All crews should review and follow TSRA CHECKLIST.

Page 21

Page 22

Page 23
HIGH RATE OF DESCENT DURING APPROACH BETWEEN 1000FT & 500FT

0V8380 SGN-DLI 05/05/2018 (ATR72)
1. Occurrences:
FO was PF, Crew avoided CB and made early turn to capture LOC RWY 09.
The A/c was high on profile, crew increased rate of descent to capture G/S.
The flight violated level 3 of high rate of descent during approach between 1000ft &
500ft. Max value recorded was -1694ft/min, limit -1500ft/min.
Max value:
- 1694ft/min
Limit: -1500ft/min
Unexperienced FO did not control well the A/c.

Findings
Captain did not advise or take control timely.
Crew needs to improve flight management and situational

awareness.
Be anticipated, configure the a/c earlier if required. Resolutions
Crew must follow SOP 2.7.7. Any deviation from stabilized
criteria, Go-around must be initiated.

Page 24
ACCIDENT: RUNWAY EXCURSION ON LANDING
LION B738 AT GORONTALO ON29/04/2018

1. Occurrences:
A Lion Air Boeing 737-800, registration PK-LOO performing flight JT-892 from
Makassar to Gorontalo (Indonesia) with 174 passengers and 7 crew, landed on
Gorontalo's runway 27 in rain at about 18:35L (10:35Z) but veered left off the runway
and came to a stop on soft ground with the nose gear collapsed and main gear struts dug
in. There are no injuries being reported, the aircraft sustained substantial damage
however.
According to ADS-B data the aircraft came to a stop about 420 meters past the runway
end near the aerodrome perimeter fence.
According to daylight photos taken the following day the aircraft veered left off the
runway digging up the soft ground left of the runway over several dozens of meters and
came to a stop abeam about midpoint of the runway.
The airline confirmed the aircraft overran the runway in rainy weather conditions. All
occupants evacuated the aircraft safely and were taken to the terminal.

Page 25
LION B738 AT GORONTALO ON29/04/2018

2. Findings:
On 08/08/2018 Indonesia's NTSC released their preliminary report reporting the crew of
an ATR-42 that had landed just prior to the accident aircraft advised that there was heavy
rain in the final area.
The Boeing crew continued their approach and touched down normally, autobrakes
activated, the spoilers and the thrust reversers deployed, then the pilots felt the rain
suddenly increased and they were able to only see the left runway edge lights.
The aircraft came to a stop about 1200 meters down the runway at a heading of 310 degrees,
the nose gear collapsed. After the aircraft came to a stop and the crew had performed the
emergency on ground procedure the PA and radio systems failed. The captain commanded
the evacuation to the lead flight attendant (FA1) directly. The forward flight attendants
(FA1 and FA4) opened the doors and initiated the evacuation, flight attendants 2, 3 and 5
positioned in the aft cabin did not notice an evacuation had been initiated. Tower was
unable to communicate with the aircraft but recognized the aircraft had experienced an
anomaly and alerted emergency services via a hand held radio (the crash bell had not yet
been connected to the new fire station). Emergency services responded and assisted with
the evacuation of the aircraft. All passengers evacuated via the slides at the front doors.
The captain (57, ATPL, 24,863 hours total, 8,585 hours on type) was pilot monitoring, the
first officer (24, CPL, 2,188 hours total, 2,188 hours on type) was pilot flying.
The local weather station reported at 17:00L: light rain, winds from eastnortheast at 3 knots,
visibility 6000 meters, QNH 1010 hPa, temperature 24 degrees C, dew point 24 degrees C,
humidity 88%, at 20:00L the weather station reported: light rain, winds from eastsoutheast
at 2 knots, visibility 6000 meters, QNH 1010hPa, temperature 24 degrees C, dew point 24
degrees C, humidity 97%.
On Apr 30th 2018 The Aviation Herald was able to retrieve the Metars :
WAMG 291200Z 12002KT 6000 -RA BKN008CB 24/24 Q1010 RMK CB IN APCH =
WAMG 291100Z 07005KT 5000 RA BKN008C B 25/24 Q1008 RMK CB IN APCH =
WAMG 291030Z 15005KT 6000 RA BKN008CB 26/24 Q1008 RMK CB IN APCH =
WAMG 291000Z 05002KT 6000 RA BKN008CB 26/24 Q1008 RMK CB IN APCH =

Page 26

Page 27
XIAMEN B738 AT MANILA ON 16/08/2018

1. Occurrences:
A Xiamen Airlines Boeing 737-800, registration B-5498 performing flight MF-8667 from
Xiamen (China) to Manila (Philippines) with 157 passengers and 8 crew, had gone around from
low height on first final approach to Manila's runway 24 due to weather, positioned for another
approach and continued for a landing on runway 24 at 23:55L (15:55Z), but went off the left
edge of the runway and came to a stop on soft ground with the left main gear collapsed and the
left engine separated from the wing. The aircraft was evacuated via slides. No injuries are being
reported, the aircraft however received substantial damage.
Manila Airport reported flight MF-8667 went off the runway at about 23:55L during a heavy
downpour. All occupants of the aircraft are safe. Investigators from the CAA Philippines are
already on site.
On Aug 17th 2018 China's CAAC reported MF8667 (B738/B5498) went left off the runway in
Manila. 157 passengers and 8 crew remained uninjured. At the time of landing there was a strong
thunderstorm, visibility 2000 meters, winds from 280 degrees at 11 knots, cloud ceiling 540
meters. The CAAC have dispatched a team of investigators to Manila to assist the Philippine
Accident Investigation. The CAA as well as the China East Aviation Authority formed a joint
working group to review Xiamen Airlines. The industry has been reminded to take resolute
measures to observe safety margins.
Related NOTAM:
B3806/18 NOTAMN
Q) RPHI/QMRLC/IV/NBO/A /000/999/1431N12101E005
A) RPLL B) 1808161945 C) 1808170400
E) RWY06/24 CLSD DUE DISABLED ACFT.
Metars:
RPLL 161700Z VRB01KT 4500 -RA FEW018CB BKN020 OVC080 24/24 Q1006 TEMPO
7000 -TSRA RMK A2971=
RPLL 161619Z 26007KT 6000 -RA BKN020 OVC080 24/24 Q1006 NOSIG RMK A2971=
RPLL 161600Z 28011KT 250V310 2000 +TSRA FEW018CB BKN020 OVC080 24/24
Q1007 TEMPO 5000 TSRA RMK A2974 CB OHD=
RPLL 161500Z 25017KT 2500 +TSRA FEW020CB BKN022 OVC080 24/24 Q1007
TEMPO 5000 TSRA 2974 CB OHD=
RPLL 161435Z 27021KT 3000 +RA SCT022 OVC090 25/25 Q1006 TEMPO FM1500 6000
RA RMK A2971=

Page 28

Page 29
XIAMEN B738 AT MANILA ON 16/08/2018

Page 30
SAFE FLIGHT!

FSR 49 Final

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FLIGHT CREW DIVISION

FLIGHT SAFETY REVIEW

FLIGHT SAFETY REVIEW

Captain was the PF for ILS 16R in good Wx condition.

Max value: -2055ft/min

Crew Crew needs to improve flight

FLIGHT CREW DIVISION

B787 SOP 2.7.7:

2.7.7 Stabilized Final Approach

FLIGHT CREW DIVISION

FAILED TO FOLLOW TAXI-OUT CLEARANCE CAUSED OTHER A/C RTO

FLIGHT CREW DIVISION

FAILED TO FOLLOW TAXI-OUT CLEARANCE CAUSED OTHER A/C RTO

TAXI TO THE CLOSED TAXIWAY

FLIGHT CREW DIVISION

FAILED TO COMPLY WITH TAXI CLEARANCE

FLIGHT CREW DIVISION

Crew failed to follow SOP 2.3.2 Taxi out, did not

Pilot who is not taxiing aircraft concentrates

FLIGHT CREW DIVISION

LANDED ON THE WRONG RUNWAY

14:52:03 LT, 1204ft,

Flight path VN7344

RWY 20L under construction

FLIGHT CREW DIVISION

LANDED ON THE WRONG RUNWAY

Barrier A/C stop A/CTouch down

FLIGHT CREW DIVISION

LANDED ON THE WRONG RUNWAY

FLIGHT CREW DIVISION

Captain was PF. The flight violated level 3 of FIRM LANDING,

Max value: 2.54G

Crew did approach and landing in strong gusting wind condition.

Crew needs to improve the landing technique.

FLIGHT CREW DIVISION

Max value 2.7G

Captain did late flare.

The landing technique should be

FLIGHT CREW DIVISION

After landing, aircraft vacated on taxi way Y12, ATC cleared

Due to communication interferences:

Crew must concentrate, do crosscheck during taxi, especially

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

All crews must assess carefully the Wx before deciding to

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

All crew members must assess Wx carefully before deciding

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

FLIGHT CREW DIVISION

HIGH RATE OF DESCENT DURING APPROACH BETWEEN 1000FT & 500FT

Unexperienced FO did not control well the A/c.

Crew needs to improve flight management and situational

FLIGHT CREW DIVISION

LION B738 AT GORONTALO ON29/04/2018

FLIGHT CREW DIVISION

LION B738 AT GORONTALO ON29/04/2018

FLIGHT CREW DIVISION