Lion Air – Boeing B737 Max 8 (PK-LQP) flight JT610

by | Oct 29, 2019 | Aviation Accident | 0 comments

Lion Air flight JT610 crashed on 29 October 2018, at about 0632 Local Time (23:32 UTC 28 October 2018).

It was a flight operated by Lion Mentari Airlines (Lion Air) with a Boeing 737-8 MAX aircraft registered PK-LQP, and was a scheduled passenger flight from Soekarno-Hatta International Airport (WIII), Jakarta with intended destination of Depati Amir Airport (WIPK), Pangkal Pinang.

When Lion Air flight JT610 disappeared from radar after informing Air Traffic Controller (ATCo) that they had flight control, altitude and airspeed issues.

The aircraft impacted the water in Tanjung Karawang, West Java, all person on board perished and the aircraft destroyed.

On 26 October 2018, the SPD (speed) and ALT (altimeter) flags on the Captain’s primary flight display first occurred on the flight from Tianjin, China to Manado, Indonesia. Following reoccurrence of these problems, the left angle of attack (AOA) sensor was replaced in Denpasar on 28 October 2018.

The installed left AOA sensor had a 21° bias which was undetected during the installation test in Denpasar.

The erroneous AOA resulted in different indications during the flight from Denpasar to Jakarta, including IAS (indicated airspeed) DISAGREE, ALT (altitude) DISAGREE, FEEL DIFF PRESS (feel differential pressure) light, activations of Maneuvering Characteristics Augmentation System (MCAS) and left control column stick shaker which were active throughout the flight.

Lion Air flight JT610
AOA indicator on PFD was sold as optional by Boeing.

The flight crew was able to stop the repetitive MCAS activation by switched the stabilizer trim to cut out.

After landed in Jakarta, the flight crew reported some malfunctions, but did not include the activation of stick shaker and STAB TRIM to CUT OUT.

The AOA DISAGREE alert was not available on the aircraft therefore, the flight crew did not report it.

The reported problem would only be able to rectify by performing tasks of AOA Disagree.
The following morning on 29 October 2019, the aircraft was operated from Jakarta with intended destination of Depati Amir Airport, Pangkal Pinang. According to the DFDR and the CVR, the flight had same problems as previous flight from Denpasar to Jakarta.

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The flight crew of Lion Air flight JT610 started the IAS DISAGREE Non-Normal Checklist (NNC), but did not identify the runaway stabilizer.

The multiple alerts, repetitive MCAS activations, and distractions related to numerous ATC communications contributed to the flight crew difficulties to control the aircraft.

Lion Air flight JT610
Lion Air flight JT610

The MCAS was a new feature introduced on the Boeing 737-8 (MAX) to enhance pitch characteristics with flaps up during manual flight in elevated angles of attack.

The investigation considered that the design and certification of this feature was inadequate. The aircraft flight manual and flight crew training did not include information about MCAS.

On 10 March 2019, similar accident occurred in Ethiopia involved a Boeing 737-8 (MAX) experiencing erroneous of AOA.

As the result of the investigation safety actions have been taken by related parties. KNKT issued safety recommendations to address safety issues identified in this investigation to Lion Air, Batam Aero Technic, Airnav Indonesia, Boeing Company, Xtra Aerospace, Indonesia DGCA, and Federal Aviation Administration (FAA).

Download preliminary Report Download final Report

Lion Air – Boeing B737 Max 8 (PK-LQP) flight JT610

Tags related to this event: AOAB737 MaxB737 Max 8BoeingIndonesiaJakartaLion AirMCASStick shaker
Event date: 20181029
Airline / Operator:Lion Air
Model: B737 Max 8
Make: Boeing
Registration: PK-LQP
msn: 43000
Location: Tanjung Karawang, Indonesia

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