DIPLOMA IN AVIATION BUSINESS

ASSIGNMENT 3
REPORT OF LION AIR ACCIDENT
Prepared For;
SUBJECT NAME AVIATION SAFETY MANAGEMENT

SUBJECT CODE ASM 1303

LECTURER MISS SITI KHATIJAH BINTI NAYAN

Prepared By;
NAME AND ID I)MUHAMED RIDZWAN SHAH BIN
MOHAMED SIDIQ (1703006)
II) AMIR ZAFRI BIN
AHMAD RADZI (1703003)
CLASS 4DAB1
DUE DATE 15 JANUARY 2019

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TABLE OF CONTENT

INTRODUCTION
1.0 SUMMARY OF THE CASE
2.0 PICTURES

2.1 Part of Lion Air JT610

2.2 Passenger and crew Lion Air JT610

2.3 Engine and Landing Gear of Lion Air JT610

3.0 ROOT CAUSE OF ACCIDENT AND INCIDENT

3.1 Technical Problem
3.2 Communication System Break Down
3.3 Poor Safety Record
4.0 CORRECTIVE ACTION PLAN TO OVERCOME THE ROOT
CAUSE
4.1 Technical Problem
4.1.1 Manufacturer Problem
4.1.2 Maintenance Error
4.1.3 Engineer Error
4.2 Communication System Break Down
4.2.1 Provide alternative satellite emergency phone
4.2.2 Provide Alerting System
4.2.3 Adopt Airborne Equipment on all aircraft

4.3 Poor Safety Record

4.3.1 Improve the Safety of Aircraft
4.3.2 Provide Professional Pilot
4.3.3 Improve the Emergency Procedure
5.0 REFERENCE

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 1. INTRODUCTION

Our group have been given an assignment regarding to incident and accident of an aircraft. We
choose the latest accident based on Lion Air’s aircraft. We will present our case about the Lion
Air’s accident at Soekarno Hatta International Airport in Jakarta to Depati Amir Airport in
Pangkal Pinang. We study the case of the accident based on the cause of the aircraft’s crash,
summary of the case, pictures or video regarding the accident and also corrective action of the
accident. This was the first major accident involving the 737 MAX and the deadliest in Lion
Air’s airline operation in 18 years history. They are some causes that make the aircraft crash. In
this report, we would like to the draw some corrective action that can prevent from be accident
again.

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1.0 SUMMARY OF THE CASE
The aircraft involved was a Boeing 737 MAX 8, registration PK-LQP, line number 7058,
powered by two CFM International LEAP engines. The aircraft was leased from China
Minsheng Investment Group (CMIG) Aviation Capital and delivered new to Lion Air on 13
August 2018. At the time of the accident, the aircraft had flown about 800 hours in service. This
was the first accident involving a 737 MAX since the type's entry into service on 22 May 2017,
and the deadliest accident involving a Boeing 737. Wreckage from the Boeing 737 MAX 8
aircraft was found in the Java Sea, off the coast of Java. All 189 passengers and crew were killed
in the accident. It became the second deadliest airplane accident in Indonesia, only below Garuda
Indonesia Flight 152. There is no sign of survivors. The cause of the crash, which involved a
plane that had been in operation since August, remains unclear.

There were 189 people on board the aircraft: 181 passengers that involves 178 adults, 1
child and 2 babies, as well as 6 cabin crew and 2 pilots. Officials confirmed that all 189
passengers and crew on board had been killed. Twenty Ministry of Finance employees, 10 Audit
Board of Indonesia employees, two auditors from the Finance and Development Inspection
Agency, three Ministry of Energy and Mineral Resources employees, three public attorneys,
three Indonesian National Police officers, six Bangka Belitung Regional People's Representative
Council members, and three judges of Indonesia's High Court and National Court, for 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. The flight's captain was 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 was an Indonesian who had logged about 5,000 hours of flight time. The
six flight attendants were also Indonesian.

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 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. On 29 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. The Transportation Ministry announced that all Indonesian Boeing 737
MAX 8 aircraft were airworthy and were allowed to resume normal operations on 31 October.
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.

Lion Air flight JT610 take off around 6:20 a.m. local time and was set to travel north
from Jakarta to Pangkal Pinang, a city on the Indonesian island of Bangka. It crashed into the sea
just 13 minutes after takeoff. Shortly after takeoff, the pilot of flight JT610 requested permission
from air traffic controllers to turn back to Jakarta’s Soekarno Hatta International Airport. The
permission is not are enter to the pilot. Around 8 minutes, the altitude of the aircraft decrease.
The flight altitude lower than 8,000ft and fall in the sea.

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2.0 PICTURES
2.1) Part of Lion Air JT610

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2.2) Passenger and crew Lion Air JT610

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2.3) Engine and Landing Gear of Lion Air JT610

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3.0 ROOT CAUSE OF ACCIDENT AND INCIDENT
The primary problem that cause the aircraft crush is because of the aircraft flight
problem. They also have some causes that make the aircraft accident.

3.1 Technical Problem

The flight data recorder showed that the plane's stick shaker, a device that warns the pilot
of an imminent stall, was active prior to and during the flight from Denpasar. The pilot of the
Denpasar flight noted several other warning signs that appeared on the flight display, including
one concerning a difference in airspeed. The very same problem occurred right before the
aircraft take off for Pangkal pinang and remained active until the crash. The findings sparked a
debate on the plane's airworthiness, despite the KNKT confirming that the malfunctions noted
during the Denpasar flight had been corrected before the plane was declared airworthy and
departed for Pangkal pinang.

Aviation analyst Gerry Soejatman of CommunicAsia said an airworthiness inspection

was aimed at ensuring that an aircraft can be dispatched and the limit for dispatch is when the
aircraft take off. Once an aircraft takes off, Soejatman said, it can have malfunctions, some of
which can render the aircraft unairworthy. If the aircraft is released on the ground and encounters
problems in the air, the pilot must, first and foremost, fly the aircraft and keep it under control.
Soejatman said there was nothing to be worried about regarding Indonesia's airworthiness
systems and standards as it had scored 90.91 per cent at the International Civil Aviation
Organization, above the global average of 78.23 per cent.

If there is anything wrong with the airworthiness system, it will be reflected in the audit
and the frequency of accidents will increase. Responding to the KNKT report, Boeing has
highlighted different responses from the pilots of the last two flights of the aircraft. The pilot
carried out three non-normal checklist procedures, including the runaway stabilizer non-normal
checklist, which is a memory item prescribed by the 737 MAX Flight Crew Operations Manual,
and reaffirmed in the Boeing Flight Crew Operations Manual Bulletin TBC-19 and FAA
Emergency Airworthiness Directive Number 2018-23-51, as the appropriate procedure to
address unintended horizontal stabilizer movement, regardless of the source.

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3.2 Communication System Break Down

The engine noise upon takeoff that lasted for the whole flight. After its initial struggle,
the aircraft eventually came to a steady climb and cruise before landing safely. It was not the
same story when the same plane took off for its one-hour flight the next day. Passengers on Lion
Air’s ill-fated flight JT610 experienced similar sickening drops in altitude in the 13 minutes they
were in the air before the plane plummeted with rapid speed into the Java Sea. The Boeing 737
MAX 8 struggled from the moment it began on what would be its final flight on Monday,
erratically climbing and dropping until it eventually plunged 1479m in just 21 seconds.

Investigators will be looking closely at pilot Bhavye Suneja’s final message to air traffic
control three minutes after takeoff, when he asked to turn around and return to Jakarta airport.
The reason for his request is unknown and communication with his plane was lost almost
immediately after he was given the all-clear to turn around. A frantic search is underway for the
plane’s black box, which will hopefully unlock the mystery of what went wrong with the Boeing
737 MAX 8 that was bought in August and had only flown 800 hours.

The reports of technical problems with Sunday’s flight from Bali, but they had been
resolved in accordance with the plane manufacturer’s procedures. But on Monday, the plane’s
altitude and speed patterns were erratic for almost all of its 13 minutes in the sky. Data from
Flightradar24 shows that Lion Air plane climbed to 640m after takeoff before dropping down to
450m. It climbed again and continued unsteadily for a few minutes between 1370m and 1630m
before fatally plunging at a breakneck speed of 9400m per minute. A normal descent for an
airliner would be about 450m to 600m per minute, aviation safety expert John Cox told
Bloomberg.

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3.3 Poor Safety Record

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 The pilot on the doomed plane asked to return to Jakarta before the crash, but it remains
unclear what caused the accident. The accident resurrected concerns about Indonesia’s poor air
safety record which until recently saw its carriers facing years-long bans from entering European
Union and US airspace. There were nearly 40 fatal aviation accidents in Indonesia over the past
15 years, according to the Aviation Safety Network, including a 1997 crash that killed 234
people, the country’s deadliest plane accident. In the years of 2000-2018 the Lion Air Airline
have the poor safety record. Lion Air which has had a number of incidents including a fatal 2004
crash, capitalized on an explosion in Indonesia’s domestic air travel market. But concerns have
been raised about pilot shortages in the industry and growth outstripping Indonesia’s strained
regulatory and technical resources.

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4.0 CORRECTIVE ACTION PLAN TO
OVERCOME THE ROOT CAUSE
4.1 Technical Problem

4.1.1 Manufacturer Problem

 The manufacturer of the aircraft’s displays or instruments must be function
because to avoid from aircraft’s accident or incident.
 The manufacturer must send all the aircraft that had been produces to test the
instrument in the aircraft, if it is works fine before sell to other airlines or who
want to bought the aircraft
 The instrument should be in good condition because the pilot needs to used most
of the equipment to flies in the air because pilot flies in blind spot.
4.1.2 Maintenance Error
 Most of the maintenance jobs needs a high focus, it can cause human error such as
sickness, lack of sleep that will cause mistakes in the works.
 As a human, sometimes we lack of energy if we work more than our limit that
will make our body tired and will exposed to default in works.
 Some of the maintenance do not follow the instrument’s procedures such as
double check the instrument if it works, that may cause the aircraft malfunction
and crash.
4.1.3 Engineer Error
 The engineer responsible for the inspection of aircraft before let go the aircraft
from the MRO services and continue the flight services.
 They should double check the aircraft condition before improving the aircraft fly.
 The engineer is responsible for ensuring an aircraft operates properly and safely to
make sure the aircraft avoid from any accident and incident.

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4.2 Communication System Break Down

4.2.1 Provide alternative satellite emergency phone

 The maintenance should provide satellite emergency phone on all aircraft to avoid
miscommunication between pilot and ATC.
 Alternative satellite emergency phone is used when the aircraft have any
instrument defect that cannot communicate with ATC.
 One of the alternative satellite emergency phones when there has an emergency
on the aircraft these can be helped the pilot communicate the ATC.
4.2.2 Provide Alerting System
 They can provide the Alerting system on aircraft to the response to the ATC that
the aircraft in problem or any emergency.
 A system provided to notify aircraft regarding is need of search and rescue aid or
any information from the pilot.
 It gives the notification to the nearest ATC about the aircraft have problem.
4.2.3 Adopt Airborne Equipment on all aircraft
 Pilot select a new frequency but equipment does not respond to change so pilot is
able to transmit or receive on this frequency.
 This also an alternative equipment on cockpit to ensure the pilot can communicate
with the ATC controller when the flight equipment is not function.
 It is also giving the warning to the ATC when the aircraft have emergency
problem.

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4.3 Poor Safety Record

4.3.1 Improve the safety of aircraft.

 The company should provide good materials in making the aircrafts, it is to avoid
the part of aircraft broke and crash.
 Used latest technology instruments of aircraft to operate the flights more safety
and comfortable.
 The airlines should have a flight plan to avoid the aircraft flies from bad
weathers, such as thunderstorm, heavy wind, hurricane, earthquakes and also
snow.
4.3.2 Provide professional pilots
 Most of the crashes are because of pilot who doesn’t have experience in flight.
 Provide pilot who have more than 5000 hours flight who can handle the plane
during emergency.
 Provide more training program to enhance pilot fitness and confident level.
4.3.3 Improve the emergency procedure
 The pilot should more aware about the safety procedure during emergency.
 The cabin crew must be alert about the consequences that might occur during
flight operation.
 The flight crew should be able to manage and maintain the margins of the safety
when the flight operation.

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5.0 REFERENCE
 https://www.bbc.com/news/world-asia-46373125
 https://www.nytimes.com/2018/11/09/world/asia/air-lion-crash-610.html
 https://en.wikipedia.org/wiki/Lion_Air_Flight_610
 https://www.radionz.co.nz/news/world/377032/lion-air-crash-airline-should-improve-
safety-culture-report
 https://www.bbc.com/news/world-asia-46014463

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