World Safety News - January - 2018 - Mobile Version

36
VOL
JANUARY 2018
WORLD SAFETY
NEWS
Accident
Norwegian B738 ATC Turns Aircraft, TCAS RA
and Turbulence Injures Two Flight Attendants
near Alicante
United B739 Indication of Loss of Thrust from
03 Both Engines 22 American B738 Slat Problem at New York
JACDEC World Safety Ranking 2017
Lion Air ranked 55th in JACDED Airline Safety Ranking 2017. JACDEC
Safety Ranking is the world’s biggest annual survey held to discover 60
biggest rank of safest airlines in the world. JACDEC was specifying the
rank based on safety index. Safety index classified the analysis result of
evaluation achievement of multiple factors such as accidents, serious
incidents, revenue passenger numbers, and safety audit.
WORLD SAFETY NEWS
Editor in Chief
Capt. E. Kallisto M.P
Managing Editor
Capt. Amir Muzakir
Production Manager
Ina Listiyani
Creative Designer
Dikky Gati Wijayanto
Content Editor
Aulia Khairunnisa
Cover Image
Shalom Mwenes
Contributors
Simon Hradecky
on The Aviation Herald
www.avherald.com
WORLD SAFETY NEWS is a Monthly Bulletin of Lion Air

Safety Publication, to increase the awareness of everyone
who work in Safety Related section in the Airlines about
the Aviation Safety and Security news in the world which
is updated periodically.
The Contents of WORLD SAFETY NEWS shall not to be

modified and its illustrations and photos shall not be
reproduced without prior written consent of Lion Air
Safety & Security Directorate
Contents
01 Incident: Westjet B738 Tail “Polish”
02 Incident: Transavia B738 Bird Strike
03 Incident: United B739 Indication of Loss of Thrust from Both Engines
04 Incident: THY B738 Lightning Strike
05 Incident: United B739 Smoke in Cockpit
06 Incident: Norwegian B738 Flaps Problem
07 Incident: United B739 Bird Strike
08 Incident: Sun Express B738 Localizer Failure
09 Incident: Delta B739 Lined Up with Taxiway for Landing
11 Incident: Sunwing B738 Cabin Did Not Pressurize
12 Incident: Ryanair B738 Fuel Leak
13 Incident: S7 B738 Engine Shut Down in Flight
14 Incident: Delta B738 Smoke in Cockpit
15 Incident: Argentinas B738 Object Hitting Tail Sparks Hijack Fears
16 Accident: Sun Express B738 Tail Strike on Departure
17 Incident: Virgin Australia B738 Hard Touch Down during Go Around
18 Accident: Norwegian B738 ATC Turns Aircraft, TCAS RA and Turbulence Injures Two Flight Attendants
19 Incident: Cayman B738 Unidentified Odour on Board
20 Incident: United B738 Gear Problem on Departure
21 Incident: Delta B739 Vibrations on Airframe
22 Incident: American B738 Slat Problem
23 Report: Europa B738 Touched Down 870m before Runway Threshold on ILS Approach
32 Incident: Lion Air B739 Communication Breakdown
33 Incident: Ethiopian B738 Lithium batteries in passenger bag overheat, Enroute
34 Incident: Air China B738 Forgotten Fire Crackers
35 Incident: Lion Air B739 Hit by Baggage Carts
November 18, 2017
Incident: Westjet B738 Tail “Polish”

at Toronto
A Westjet Boeing 737-800, registration C-GRTB performing flight WS-

1116 from Toronto,ON (Canada) to Las Vegas,NV (USA) with 165 passengers
and 6 crew, was departing Toronto’s runway 24R when the crew felt a tail
strike during rotation. The crew stopped the climb at 10,000 feet first
for about 15 minutes, then climbed briefly to FL200 and descended to
11,000 feet again and depressurized the aircraft. The aircraft burned off
fuel for about 2 hours, then returned to Toronto for a safe landing about
2:40 hours after departure.
The Canadian TSB reported maintenance performed a tail strike inspection

and found the tail skid within serviceable limits and returned the aircraft
to service.
1 World Safety News | Vol 36 January 2018

December 1, 2017
Incident: Transavia B738 Bird Strike

at Amsterdam
A Transavia Boeing 737-800, registration PH-HZX performing flight

HV-6002 from Porto (Portugal) to Amsterdam (Netherlands), concluded
a seemingly uneventful flight with a safe landing on Amsterdam’s runway
36C and taxied to the apron maintaining routine communication.
The aircraft however was unable to continue its schedule, next flight
assigned was HV-5193, and remained on the ground in Amsterdam for
about 21 hours before returning to service.
A passenger booked on flight HV-5193 reported they were already wait-

ing at the gate for boarding when the gate was changed. After boarding
another aircraft the crew explained the other aircraft had suffered a bird
strike on approach to Amsterdam and was damaged, hence needed to
be taken out of service.

December 4, 2017
Incident: United B739 Indication of Loss

of Thrust from Both Engines
near Chicago
A United Boeing 737-900, registration N63899 performing flight
UA-1549 from Boston,MA to Chicago O’Hare,IL (USA), was descending
through about FL110 towards Chicago when the crew declared emer-
gency reporting the loss of thrust in both engines (CFM56). ATC immedi-
ately cleared the flight direct to Chicago and kept runway 22L sterile for
the emergency redirecting all arrivals for 22L onto 22R.
About 10 minutes later the crew advised it had been just an indication
issue and an issue with engine mode control, they would be able to land
just fine and vacate the runway on own power. The aircraft deviated
around weather and continued for a safe landing on runway 22L about 15
minutes after the emergency call.
The occurrence aircraft is still on the ground about 12 hours after landing.

December 6, 2017
Incident: THY B738 Lightning Strike

at Istanbul
A THY Turkish Airlines Boeing 737-800, registration TC-JGG performing

flight TK-1899 from Istanbul Sabiha Gokcen (Turkey) to Vienna (Austria),
was climbing out of Sabiha Gokcen’s runway 06 when the crew stopped
the climb at FL140 following a lightning strike. The aircraft returned to
Sabiha Gokcen for a safe landing on runway 06 about 25 minutes after
departure.
A replacement Boeing 737-800 registration TC-JGP reached Vienna

with a delay of 2:15 hours. The occurence aircraft is still on the ground
about 33 hours after landing back.
The airline confirmed the aircraft returned to Istanbul’s Sabiha Gokcen

Airport following a lightning strike. A replacement aircraft took the pas-
sengers to Vienna.

December 8, 2017
Incident: United B739 Smoke in Cockpit

near Newark
A United Boeing 737-900, registration N62889 performing flight UA-

1048 from Newark,NJ (USA) to Cancun (Mexico) with 185 people on
board, was climbing through about FL180 out of Newark when the crew
donned their oxygen masks reporting smoke in the cockpit and returned
the aircraft to Newark. The aircraft landed safely back on Newark’s runway
22L about 30 minutes after departure.
A replacement Boeing 737-900 registration N67845 reached Cancun

with a delay of 2.5 hours.

December 9, 2017
Incident: Norwegian B738 Flaps

Problem at Funchal
A Norwegian Boeing 737-800, registration LN-NGC performing flight

DY-1784 from Oslo (Norway) to Funchal (Portugal) with 84 people on
board, was on final approach to Funchal descending through about 700
feet when the crew initiated a go around reporting a flaps problem and
decided to divert to Porto Santo (Portugal) where the aircraft landed
safely about 30 minutes later.
The occurrence aircraft is still on the ground in Porto Santo about 4 hours
after landing.

December 9, 2017
Incident: United B739 Bird Strike

at Spokane

255 from Denver,CO to Spokane,WA (USA), was on approach to Spo-
kane’s runway 03 when the aircraft flew through a flock of birds. The
aircraft continued for a safe landing.
The FAA reported the aircraft sustained damage to wings and tail and
rated the occurrence an incident.

December 13, 2017
Incident: Sun Express B738 Localizer

Failure at Amsterdam
A Sun Express Boeing 737-800, registration TC-SEO performing flight

XQ-722 from Kayseri (Turkey) to Amsterdam (Netherlands), was on final
ILS approach to Amsterdam’s runway 18C being established on both
localizer and glideslope, when the crew reported they got a warning on
the localizer and queried tower about the status, tower confirmed the
localizer was off. The crew initiated a go around from about 1100 feet
MSL, positioned for another approach to runway 18R and landed safely
about 15 minutes after the go around.
Tower asked the next approach to runway 18C whether they were able
to see the runway, the crew responded in the negative and also per-
formed a missed approach.

November 29, 2017
Incident: Delta B739 Lined Up with

Taxiway for Landing at Atlanta
A Delta Airlines Boeing 737-900, registration N852DN performing flight

DL-2196 from Indianapolis,IN to Atlanta,GA (USA), was on final approach
to runway 09R cleared to land on runway 09R, when tower instructed
the aircraft to go around from low height, the crew initiated a go around.
Tower subsequently explained it appeared they were over the taxiway.
The aircraft positioned for another approach to Atlanta and landed safely
on runway 10 about 15 minutes later.
The NTSB reported the aircraft was aligned with the runway center line
initially, however, during short final about 1nm before the runway threshold
began to veer left and lined up for the taxiway N parallel to the runway.
The taxiway was occupied. The aircraft went around from about 100 feet
AGL already past the begin of the taxiway. The NTSB reported cloud
tops were at 300 feet AGL. Both crew members reported that they
were right of the runway center line on an ILS approach, the localizer
showed a full deflection indicating they were right of the runway. The
captain reported he called the go around at decision height (200 feet
AGL) because he couldn’t see the runway or airport environment, the
first officer also reported they called for and initiated the go around
before the air traffic controller instructed the go around.

The flight data recorder was read out, first results suggest that the auto-
pilot was disconnected at 1200 feet AGL at a heading of 100 degrees,
the autothrottle was disengaged at 500 feet AGL. At about 400 feet
the heading changed briefly to 81 degrees, then the aircraft turned to
87 degrees, during that time the aircraft descended from 400 to 100
feet AGL, at 100 feet the pitch changed from 2 degrees to 8 degrees,
the aircraft turned right to about 105 degrees. The minimum altitude was
recorded at 60 feet AGL.
The airline reported they are cooperating with the investigation. The
aircraft was initially right of the center line, the crew corrected but
obviously overcorrected. The first officer was pilot flying and the captain
pilot monitoring.

December 10, 2017
Incident: Sunwing B738 Cabin Did Not

Pressurize at Vancouver
A Sunwing Boeing 737-800, registration C-FTJH performing flight

WG-211 from Vancouver,BC (Canada) to Puerto Vallarta (Mexico) with 193
passengers and 6 crew, was climbing through about 13,000 feet out of
Vancouver when the crew received a cabin altitude warning, performed
an emergency descent, burned off fuel and returned to Vancouver for a
safe landing about 65 minutes after departure.

December 16, 2017
Incident: Ryanair B738 Fuel Leak

near Milan
A Ryanair Boeing 737-800, registration EI-EMA performing flight FR-

1438 from Milan Malpensa to Palermo (Italy), was climbing through FL330
out of Milan when the crew decided to return to Milan Malpensa due to
indications of a fuel leak. The aircraft landed safely back on Malpensa’s
runway about 30 minutes after departure.
A replacement Boeing 737-800 registration EI-EVM reached Palermo

as flight FR-1498 with a delay of 2:20 hours.
The occurrence aircraft is still on the ground about 12 hours after landing
back

December 18, 2017
Incident: S7 B738 Engine Shut Down

in Flight near Blagoveschensk
An S7 Sibir Airlines Boeing 737-800, registration VP-BUL performing

flight S7-3269 from Novosibirsk to Yuzhno-Sakhalinsk (Russia) with 156
passengers and 6 crew, was enroute at FL350 about 110nm northeast
of Blagoveschensk (Russia) when the crew observed a low oil pressure
indication for the left hand engine (CFM56), shut the engine down and
diverted to Blagoveschensk for a safe landing about 30 minutes later.
Rosaviatsia opened an investigation into the occurrence.

December 21, 2017
Incident: Delta B738 Smoke in Cockpit

near Colorado Springs
A Delta Airlines Boeing 737-800, registration N3734B performing flight

DL-1406 from Raleigh-Durham,NC to Los Angeles,CA (USA), was enroute
at FL360 about 130nm eastsoutheast of Colorado Springs,CO (USA)
when the crew reported smoke in the cockpit and diverted to Colorado
Springs for a safe landing about 30 minutes later. Attending emergency
services did not find any trace of fire or heat.
A replacement Boeing 737-800 registration N3744F reached Los An-

geles with a delay of 4 hours.
The occurrence aircraft remained on the ground for about 7 hours, then
returned to service.

December 22, 2017
Incident: Argentinas B738 Object

Hitting Tail Sparks Hijack Fears
at Buenos Aires
An Aerolineas Argentinas Boeing 737-800, registration LV-FRQ per-
forming flight AR-1368 from Buenos Aires Aeroparque,BA (Argentina) to
Santa Cruz (Bolivia), departed Aeroparque’s runway 13 and was climb-
ing out of Buenos Aires when the crew stopped the climb at FL200
reporting a “tail blow”, an object had hit the tail of the aircraft. ATC
understood hijack as reason and triggered according alerts with author-
ities. The aircraft returned to Buenos Aires but diverted to Buenos Aires’
Ezeiza Airport. The aircraft burned off fuel at 5000 feet and landed
safely on Ezeiza’s runway 11 about 90 minutes after departure. The mis-
understanding between crew and ATC was cleared up.
The airline reported an object hit the tail of the aircraft, an inspection
found no significant damage to the aircraft. The confusion between ATC
and crew arose because of use acronyms. The aircraft is estimated to
depart again later the day.

December 23, 2017
Accident: Sun Express B738 Tail Strike

on Departure at Hamburg
A Sun Express Boeing 737-800, registration TC-SEO performing flight

XQ-171 from Hamburg (Germany) to Antalya (Turkey), departed Hamburg’s
runway 33 when the crew received a tail strike indication, stopped the
climb at 4000 feet and advised air traffic control about the tail strike.
The controller understood bird strike and alerted emergency services
accordingly. The aircraft positioned for a return to Hamburg and landed
safely on Hamburg’s runway 23. Emergency services attending to the
aircraft still believing to deal with a bird strike reported they were seeing
substantial damage to the underside of the tail section clarifying the
aircraft had sustained a tail strike.
The occurrence aircraft is still on the ground about 29 hours after landing
back.

December 26, 2017
Incident: Virgin Australia B738 Hard

Touch Down during Go Around
at Maroochydore
A Virgin Australia Boeing 737-800, registration VH-VUX performing flight VA-
1507 from Melbourne,VI to Maroochydore,QL (Australia), was on final approach
to Maroochydore’s runway 36 when the crew initiated a go around, the aircraft
touched down before climbing out again. The aircraft entered a hold at 4000
feet while the crew assessed the situation. The aircraft subsequently diverted to
Brisbane, where the aircraft landed on runway 19 without further incident about
40 minutes after the go around.
Passengers reported the aircraft hit the runway hard with loud noise.
The airline reported: “The safety of our guests and crew is our number one prior-
ity. VA1507 was not able to safely land at Maroochydore Airport yesterday morn-
ing so the Captain made the decision to divert to Brisbane Airport, where guests
were taken by bus to Maroochydore Airport. We apologise for any inconvenience
caused” in response to our inquiry asking: “Is the narrative by the passengers
correct, that there was a hard touchdown associated with noise? Did this indeed
result in a tail strike? What can you say preliminarily about the damage - would
the damage need to be rated substantial or minor? How many passengers and
crew were on board?”
The ATSB indicated their offices are closed until Jan 2nd 2018, no inquiries would
be answered until then. The occurrence aircraft remained on the ground in
Brisbane about 26 hours after landing in Brisbane before returning to service. No
weather data are available for Maroochydore.

October 18, 2017
Accident: Norwegian B738 ATC Turns

Aircraft, TCAS RA and Turbulence
Injures Two Flight Attendants near
Alicante
Picture 1. Infrared Satellite Image SEVIRI Oct 18th 2017 13:00Z (Graphics: AVH/Meteosat):
A Norwegian Air International Boeing 737-800, registration EI-FJJ performing flight

D8-5321 from Oslo (Norway) to Alicante,SP (Spain) with 178 passengers, was descending
towards Alicante while being surrounded by cumulonimbus cloud. The aircraft had been
cleared to descend to FL190 and was already level at FL190, when the crew received
instruction by ATC to turn left 90 degrees shortly followed by a TCAS resolution advisory to
descend below the cleared FL190. While descending between FL190 and FL180 on TCAS
instruction the aircraft encountered turbulence causing injuries to two flight attendants. The
aircraft continued to Alicante for a landing without further incident.
Spain’s CIAIAC reported one flight attendants received a serious leg injury, the other a
minor back injury when the aircraft turned left 90 degrees following an ATC instruction and
descended from the assigned FL190 to FL180 due to a TCAS RA and thus passed through
a zone of turbulence. After being clear of conflict the flight crew was informed about the
injuries of the flight attendants and continued the flight for a landing at destination without
further incident. The CIAIAC opened an investigation into the occurrence.

December 27, 2017
Incident: Cayman B738 Unidentified

Odour on Board at Grand Cayman
A Cayman Airways Boeing 737-800, registration VP-CNG performing

flight KX-505 from Chicago O’Hare, IL (USA) to Grand Cayman (Cay-
man Islands), was descending through about 8000 feet on approach to
Grand Cayman when the crew requested priority and emergency ser-
vices on stand by reporting an unidentified odour in the cabin. The aircraft
continued for a safe landing on runway 08.
The airline confirmed the crew requested priority and emergency ser-
vices on stand by due to an unidentified odour in the cabin. The aircraft
landed safely. A maintenance inspection did not identify any defects or
anomalies causing the odour, the aircraft was returned to service.
The aircraft returned to service about 14.5 hours after landing.

December 30, 2017
Incident: United B738 Gear Problem on

Departure at Saint Lucia

1643 from Saint Lucia Hewanorra (Saint Lucia) to Newark,NJ (USA) with
about 150 people on board, was climbing out of Saint Lucia when the
crew could not fully retract the landing gear, stopped the climb, burned
off fuel and returned to Hewanorra Airport for a safe landing about 2
hours after departure.
The flight was cancelled.

December 30, 2017
Incident: Delta B739 Vibrations on

Airframe at Atlanta
A Delta Airlines Boeing 737-900, registration N888DU performing flight

DL-2109 from Atlanta,GA to Salt Lake City,UT (USA), was climbing out of
Atlanta’s runway 26L when the crew stopped the climb at about 12,000
feet reporting vibrations on the airframe and requested to return to At-
lanta, no further assistance was needed. The crew subsequently reported
the vibrations appeared to come from a nose gear door. The aircraft
landed safely on runway 26R about 20 minutes after departure.
A replacement Boeing 737-900 registration N818DA reached Salt Lake

City with a delay of 2.5 hours.
A passenger reported the captain announced shortly after takeoff they

had strange vibrations and were returning to Atlanta. Emergency services
inspected the aircraft, then the aircraft taxied to the gate. Eventually the
passengers disembarked following an announcement the aircraft could
not be repaired at the gate. The captain later announced the source of
the vibration was identified as one of the nose gear doors. A replace-
ment aircraft took them to Salt Lake City with a delay of 2.5 hours.

December 31, 2017
Incident: American B738 Slat Problem

at New York
An American Airlines Boeing 737-800, registration N972AN perform-

ing flight AA-1609 from Bermuda (Bermuda) to New York JFK,NY (USA)
with 144 people on board, was on approach to New York when the crew
stopped the descent at 3000 feet reporting they had a flight control
issue and might be declaring emergency. About 5 minutes later the
crew explained the leading edge devices were stuck in the one o’clock
position, declared emergency, requested emergency services to attend
the aircraft and advised they were going to stop on the runway 31L for a
brief inspection of brakes and checks for leaks. The aircraft landed safely
on runway 31L at a higher than normal speed about 30 minutes after
stopping the descent. The aircraft stopped on the runway, emergency
services reported the brakes appeared hot but there were no leaks,
emergency services followed the aircraft to the apron.

October 28, 2017
Report: Europa B738 Touched Down

870m before Runway Threshold on
ILS Approach at Katowice
An Air Europa Boeing 737-800, registration EC-HBM performing
charter flight UX-911 from Beirut (Lebanon) to Katowice (Poland) with 114
passengers and 8 crew, was on an ILS approach to Katowice’s runway
27 at 03:05L (02:05Z) when the aircraft touched down about 870
meters/2850 feet before the runway threshold, collided with approach
lights, bounced and touched down again for a total of four touch downs
before the aircraft slowed to taxi speed now on the runway and taxied
to the apron. There were no injuries, the aircraft sustained substantial
damage to engines, fuselage, flaps and horizontal stabilizer and took out
most of the approach lights runway 27.
Poland’s PKBWL rated the occurrence an accident and stated, that the
investigation can still not be considered complete (10 years after the
occurrence). The PKBWL however released their final report annotating
that the investigation could be reopened any time should new evidence
surface and concluding the probable causes of the accident were:
Cause of the accident and contributing factors
The cause of the accident was failure to execute a missed approach pro-
cedure even if the criteria of a stabilized approach were not met during
an attempt to intercept G/S “from above” at excessive descent rate,
under meteorological conditions below the minimum for the aerodrome.

Factors contributing to the occurrence
1. Errors in flight crew co-operation (inadequate CRM).
2. The failure of the crew to perform the approach in accordance with

the published procedure.
3. No response of the crew to the warning signals generated by GPWS.
4. Landing on aerodrome equipped with ILS CAT I with autopilot engaged.
The PKBWL reported the aircraft was flown by a captain (59, ATPL, about
15,000 hours total, about 5,000 hours on type, certified CATII/CATIII
operations) acting as pilot monitoring, a first officer (37, ATPL, about
5000 hours total, about 2000 hours on type, certified CATII/CATIII
operations) acting as pilot flying and an instructor (54, ATPL, more than
15,000 hours total) acting as pilot in command. The captain was expect-
ed to take controls at decision height and become pilot flying, the first
officer was expected to hand controls to the captain at decision height
and assume the role as pilot monitoring.
While descending towards Katowice the instructor and captain discussed

the weather situation, both concluded the weather was “just enough”
and decided to go ahead with the approach. While contacting Kato-
wice tower the crew received the present weather conditions: “wind
230, 1kt, visibility 300m, RVR 250m, fog, clouds broken 100ft, second
layer 600ft, temp.+8, dewpoint +8, QHH 1027.”, about 3.5 minutes later
ATC reported: “wind var. 2kt, visibility 300m, fog, clouds broken 100ft,
temp.+8, dewpoint +8, QNH 1027, expect approach to RWY 27, trans level
80, RWY wet, braking action medium, and copy RVR from treshold 27,
450m, 450m, 650m.”

The aircraft was cleared to descend to 4000 feet and to report when
over KTC NDB. The first officer suggested they should use the published
procedure due to poor visibility, the captain however decided to fly a
straight in approach to reduce fuel consumption.
About 6.4nm before the runway threshold, already established on the

localizer, the aircraft was still descending at 1560 fpm above the glide
slope (deviation according to FDR 5.62 dots fly down) at radar altitude
3072 feet, engines idle at 152 KIAS, when the crew configured the air-
craft for landing (gear down, flaps 41 degrees).
At 2:03:24Z the crew received landing clearance on runway 27, tower

reported: “wind 240 deg., 2kt, RVR from threshold 27 500m, 500m,
900m. “ The crew requested the runway lights at maximum intensity,
tower confirmed the lights were set to maximum intensity.
The crew discussed for more than 12 seconds that they were flying too
high, the autopilot in LVL CHG mode adopted a vertical rate of descent
of 1720 fpm. The autopilot was briefly selected to V/S which reduced the
rate of descent, the captain urged “go down”, the mode was returned to
level change, the rate of descent increased again.
Passing over KTC NDB the aircraft was at 1274 feet radar altitude, 2200
feet MSL descending at 1848 fpm, the aircraft should have passed KTC at
1790 feet MSL, the first officer stated they had passed KTC about 300
feet above target. 15 seconds the captain stated: “OK, entering in slope”,
9 seconds later the captain announced: “approaching minimum”.
One second later, 02:05:01Z and 17 seconds before first touchdown, the
aircraft crossed the glideslope descending at 1664 fpm at radar altitude
388 feet, the GPWS sounded “SINK RATE”, the autopilot changed from
Level Change to GlideSlope.

12 seconds before touchdown the automatic call out “APPROACHING
MINIMUMS” occurred, the captain shouted twice “keep that slope”. De-
scending through 198 feet AGL another GPWS “SINK RATE” call occurred
at 1624 fpm rate of descent.
9 seconds before touchdown the GPWS sounded “PULL UP!”, rate of

descent 1760 fpm, RA (radar altitude) 163 feet.
8 seconds before touchdown the control column was pulled, the engines
accelerated, the GPWS “PULL UP” warning ceased 6 seconds before first
touchdown.
5 seconds before touchdown the captain spotted the approach lights and
called “I have it”, the first officer confirmed “your controls”. The GPWS
sounded SINK RATE twice, rate of descent 1112 fpm at 50 feet AGL.
2 seconds before touchdown a first sound of impact was recorded by

the CVR, probably first collision with an approach light post.
1 second prior to touchdown, 3 feet AGL, the captain commented: “Oh,

my God”.
The aircraft touched down at 6 degrees nose up and 144 KCAS, the
thrust levers were momentarily placed into the takeoff position, a takeoff
configuration warning occurred. The stick shaker activated, the second
touchdown occurred at +1.799G at 5.8 degrees nose up. The thrust
levers were retarded. Two more bounced occurred, then the thrust
reversers were deployed, autothrottles were disconnected, the autopilot
was disengaged, the aircraft reached the runway, taxied off the runway
and went to the stand.

The PKBWL wrote:
Five minutes after the first touchdown, during taxiing, the Captain intend-
ed to inform the traffic controller about the occurrence, he said:
2:10:34 hrs - “We should say something to the tower, because we have
lights broken?”
and:
2:10:42 hrs - ... “it must be a lot of lights broken, and other things”
the instructor responded:
2:10:44 hrs - “......wait, wait, wait”.
As a result, the crew did not inform air traffic services about the occur-
rence.
The PKBWL analysed that the last RVR information provided by tow-
er “RVR RWY27 500m, 500m and 900m” were below the required
minima, however, this did not prompt the crew to divert to their alternate
with better weather conditions.
The PKBWL analysed the decision by the captain to proceed with the
straight in approach probably was triggered by concerns over an exces-
sivefuel consumption during the flight, however, there was still sufficient
fuel in the tanks to divert to Warsaw.

The PKBWL analysed:
Both pilots at the controls were aware that they were too high for
straight-in approach (G/S was below the airplane), hence it required a
greater descent rate (1600-2000 ft/min - more than twice the normal
descent rate on G/S) and interception of G/S from above. It caused
that 17 seconds before the first contact with the ground the airplane
crossed G/S and continued the flight below G/S.
Increase in the aircraft pitch (from -3 deg to +6 deg) to intercept G/S

(this time from below) occurred just above the ground, causing that the
airplane was close to touchdown attitude. Therefore, the damage to the
airplane resulted from the collision with the approach lights rather, and
not from the touchdown.
The PKBWL emphasized: “Any significant deviation from planned flight path,
airspeed, or descent rate should be announced (by PM). The decision to
execute a go-around is no indication of poor performance.”
Based on the FDR analysis the PKBWL analysed that the approach was
unstabilized contrary to the Flight Crew Training Manual and wrote:
As a result of unstabilized approach, where G/S was intercepted from

above at a great descent rate, premature multiple touchdowns of the
aircraft and collisions with the ground obstacles occured. Approach to
landing and landing were performed with B autopilot engaged, which the
crew disengaged only after the landing roll.
The aircraft intercepted the localizer at RA 3800 feet which was 1700
feet above the glideslope and continued the approach reaching more
than 2000 fpm rate of descent temporarily and wrote: “Boeing com-
pany concluded that AP attempted to capture G/S, but an excessive
descent rate caused fast crossing of G/S and triggered BEAM ANOMA-
LY DETECTION.”

The PKBWL concluded their analysis with the analysis of flight crew ac-
tions:
2.4.1. The crew did not conduct LANDING CHECKLIST.
2.4.2. G/S capturing from above with a high descent rate and G/S cross-
ing at a distance of 1.5NM from the runway threshold in the absence of
visual reference to the ground is a HIGHLY DANGEROUS maneuver which
led to the accident.
2.4.3. In the existing weather conditions, it was necessary to divert to an

alternate aerodrome having better conditions, e.g. EPWR or EPWA.
2.4.4. When attempting to land on EPKT, it was necessary to perform the

published approach procedure instead of straight-in approach, which
forced the crew to fly at a high vertical speed in the absence of visual
reference to the ground.
2.4.5. The briefing prior to the descent was incomplete, omitting

STRAIGHT-IN approach, which was actually performed.
2.4.6. The crew did not respond to the SINK RATE and PULL UP messages
generated by GPWS over a dozen seconds before the first contact of
the airplane with the ground.
2.4.7. PIC, as a commander and also as an instructor should have super-

vised the correctness of the crew’s decisions and their correct imple-
mentation. In the Commission’s opinion, PIC should have seated “at con-
trols” during take-off, initial climb, approach and landing, especially if those
flight phases have taken place in weather conditions close to minima.
2.4.8. Landing with AP engaged led to G/S crossing and the airplane
passing below G/S, which resulted in its premature contact with the
ground.

All of the above errors indicate that the crew did not apply the CRM
principles.
The crew’s failure to inform the airport services about the touchdown
short of RWY threshold and damage to the approach lights system had
an adverse impact on safety of subsequent landing aircraft. That failure
was a violation of the rules of conduct in the area of aviation safety, and
was also contrary to the ethics of a professional pilot.
Picture 2. Some of the aircraft damage (Photo: PKBWL)
Picture 3. The approach lights (Photo: PKBWL)

Picture 4. ILS runway 27 approach chart (Graphics: PKBWL):

December 5, 2017
Incident: Lion Air B739 Communication

Breakdown at China Airspace
Lion Air B739 was flying a commercial flight from Soekarno-Hatta In-
ternation Airport to Haikou International Airport, Hainan province. During
pre-flight check no significant defect found related to communication
system problem. Aircraft was taking-off normally without any suspicious
event occurred.
During Cruise, flight crew initial contact with Sanya control at waypoint
BUNTA and no information to be report by ATC at certain waypoint. Along
the route from point BUNTA until SYX flight crew still monitor on 130.2
MHz, Sanya control and 121.5 MHz International Air Destress frequency.
When aircraft passed by G221 from BUNTA to SYX control area, ATC con-
troller contacted aircraft. However, ATC did not get any reply from pilot.
Then, controller launched radio failure procedure and contact aircraft via
another frequency.
Approaching point SYX, flight crew replied ATC via 130.2 MHz while Sanya
controller at frequency 122.9 MHz. During this period, no effect impairing
safety was occurred. Then, communication between ATC and the aircraft
was established to continue flight. The aircraft continued to fly normally.
The aircraft landing without any further incident occurred and the pas-
sengers disembarked safely. After landing and discussed with first officer
found that they did not report at compulsory report point at KAGUK.

November 17, 2015
Incident: Ethiopian B738 Lithium

batteries in passenger bag overheat,
Enroute near Botswana
An Ethiopian Airlines Boeing 737-800, registration ET-AQO performing
flight ET-829 from Addis Ababa (Ethiopia) to Gaborone (Botswana), was
enroute about three hours into the five hour flight when white smoke
began to develop in the cabin. Cabin crew identified a passenger’s hand-
bag as source of the smoke and discharged a fire extinguisher onto and
into the hand bag, the smoke however continued. Another passenger
came to help, opened the bag and noticed that two smartphone Lithium
batteries had been tied together and one of them was melting down
causing heat damage to the surroundings and the bag. The passenger
separated the batteries, the batteries were subsequently cooled down,
and the smoke ceased. The aircraft continued to Gaborone and landed
there without further incident.
The aircraft was able to continue for the next sector to Cape Town
(South Africa) on schedule and delivered the helping passenger travelling
home in Cape Town on time.

March 6, 2012
Incident: Air China B738 Forgotten fire

crackers near Nanning
An Air China Boeing 737-800, registration B-5500 performing flight

CA-1370 from Sanya to Beijing (China), was enroute about half way into
the flight when a passenger found a string of fire crackers in her hand
bag, the fire crackers had been left there by her nephew and had been
forgotten. The woman, accompanied by the boy, handed the firecrackers
to the flight attendants, who in turn informed the captain, who in turn
decided to divert to Nanning to dispose of the fire crackers. The aircraft
landed safely in Nanning.
In the meantime a full scale bomb alert response had been mounted, the
aircraft was directed to a remote area, passengers needed to disembark,
collect their checked luggage and go through security again, the aircraft
was searched without any further explosives found and finally continued
reaching Beijing with a delay of 3.5 hours.
Passengers raised the question on China’s Weibo service (similiar to Twit-

ter) how the fire crackers made it through security screening in Sanya.

December, 2017
Incident: Lion Air B739 Hit by Baggage

Carts at Soekarno-Hatta Airport
Lion Air B739 was parking at stand B43 Soekarno – Hatta Airport. The
aircraft was planning to fly a commercial flight. The aircraft was going
to perform loading process to the aircraft. Then, BTT Operator drove
luggage cart from break down area terminal alfa to transport baggage to
parking stand B43.
When the luggage cart arrived at B43, BTT operator stopped near the
aircraft to remove luggage cart that is going to be placed in FWD
compartment. However, loading master informed that the luggage cart
containing baggage to placed in AFT compartment. Then, BTT operator
manuvered with 5 km/hour speed. Apparently, the last cart containing
oversize baggage and bumped another cart (no. 013) that is in the
process of unloading at fwd compartment. Then, the cart no. 013
accidentally pushed by the luggage cart and hit the aircraft fuselage.
The ground staff then informed the incident to their supervisor so that
the aircraft can be check further. Then, Engineer came to the aircraft to
check the part of the aircraft that was hit by the cart. The fuselage was
sratch and dent. The engineer stated that the aircraft can not be release
to flight. The aircraft should be grounded for further maintenance.

Picture 5. Scratch and dent part of the aircraft (Photo: Internal Source)
Picture 6. Luggage cart condition (Photo: Internal Source)

World Safety News - January - 2018 - Mobile Version

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

World Safety News - January - 2018 - Mobile Version

Uploaded by

Copyright:

Available Formats

36

WORLD SAFETY NEWS is a Monthly Bulletin of Lion Air

The Contents of WORLD SAFETY NEWS shall not to be

Incident: Westjet B738 Tail “Polish”

A Westjet Boeing 737-800, registration C-GRTB performing flight WS-

The Canadian TSB reported maintenance performed a tail strike inspection

1 World Safety News | Vol 36 January 2018

Incident: Transavia B738 Bird Strike

A Transavia Boeing 737-800, registration PH-HZX performing flight

A passenger booked on flight HV-5193 reported they were already wait-

2 World Safety News | Vol 36 January 2018

Incident: United B739 Indication of Loss

3 World Safety News | Vol 36 January 2018

Incident: THY B738 Lightning Strike

A THY Turkish Airlines Boeing 737-800, registration TC-JGG performing

A replacement Boeing 737-800 registration TC-JGP reached Vienna

The airline confirmed the aircraft returned to Istanbul’s Sabiha Gokcen

4 World Safety News | Vol 36 January 2018

Incident: United B739 Smoke in Cockpit

A United Boeing 737-900, registration N62889 performing flight UA-

A replacement Boeing 737-900 registration N67845 reached Cancun

5 World Safety News | Vol 36 January 2018

Incident: Norwegian B738 Flaps

A Norwegian Boeing 737-800, registration LN-NGC performing flight

6 World Safety News | Vol 36 January 2018

Incident: United B739 Bird Strike

A United Boeing 737-900, registration N66803 performing flight UA-

7 World Safety News | Vol 36 January 2018

Incident: Sun Express B738 Localizer

A Sun Express Boeing 737-800, registration TC-SEO performing flight

8 World Safety News | Vol 36 January 2018

Incident: Delta B739 Lined Up with

A Delta Airlines Boeing 737-900, registration N852DN performing flight

9 World Safety News | Vol 36 January 2018

10 World Safety News | Vol 36 January 2018

Incident: Sunwing B738 Cabin Did Not

A Sunwing Boeing 737-800, registration C-FTJH performing flight

11 World Safety News | Vol 36 January 2018

Incident: Ryanair B738 Fuel Leak

A Ryanair Boeing 737-800, registration EI-EMA performing flight FR-

A replacement Boeing 737-800 registration EI-EVM reached Palermo

12 World Safety News | Vol 36 January 2018

Incident: S7 B738 Engine Shut Down

An S7 Sibir Airlines Boeing 737-800, registration VP-BUL performing

Rosaviatsia opened an investigation into the occurrence.

13 World Safety News | Vol 36 January 2018

Incident: Delta B738 Smoke in Cockpit

A Delta Airlines Boeing 737-800, registration N3734B performing flight

A replacement Boeing 737-800 registration N3744F reached Los An-

14 World Safety News | Vol 36 January 2018

Incident: Argentinas B738 Object

15 World Safety News | Vol 36 January 2018

Accident: Sun Express B738 Tail Strike

A Sun Express Boeing 737-800, registration TC-SEO performing flight

16 World Safety News | Vol 36 January 2018

Incident: Virgin Australia B738 Hard

17 World Safety News | Vol 36 January 2018

Accident: Norwegian B738 ATC Turns

A Norwegian Air International Boeing 737-800, registration EI-FJJ performing flight

18 World Safety News | Vol 36 January 2018

Incident: Cayman B738 Unidentified

A Cayman Airways Boeing 737-800, registration VP-CNG performing

The aircraft returned to service about 14.5 hours after landing.