October 30, 2018

On Oct. 29, 2018 a Lion Air (JT) Boeing 737-8 MAX operating flight JT-610 from Jakarta’s Soekarno–Hatta International Airport (CGK) to Pangkal Pinang’s Depati Amir Airport (PGK) in Indonesia crashed into the sea shortly after takeoff from CGK. Indonesian authorities say it is highly unlikely that any of the 189 people on board survived.


The specific cause of the accident is not currently known, though Indonesian authorities and media outlets have said that the aircraft experienced technical problems, both on a previous flight and during the flight that crashed. It is not clear if these technical issues were related to each other, or if they played a major role in the accident. Lion Air is listed as Preferred in WorldAware’s Worldcue Airline Monitor, but its Preferred rating is marginal. Should the investigation into Flight JT-610’s crash reveal major shortcomings in Lion Air’s operational and safety standards, WorldAware will likely downgrade the carrier to Not Preferred.


What We Know


Lion Air Flight JT-610 took off from CGK at 0620 local time. Shortly after takeoff, the pilots reported a technical problem and requested permission to land, which was granted. Indonesian authorities have not indicated what sort of technical problem was reported. While some sources have indicated that the pilots asked to return to CGK, others have said they asked to land at Jakarta’s smaller Halim Perdanakusuma International Airport (HLP), which was near the aircraft’s flight path; the latter would have been an unusual choice indicating that the aircraft had a problem so severe that the pilots didn’t think they could make it back to CGK. Ultimately, the aircraft did not descend towards either airport, but flew over the ocean before crashing about 13 minutes after taking off. The weather at the time of the accident was good, with scattered clouds, calm winds, and good visibility at sea level. The accident occurred during the daytime.

Several media outlets and social media accounts have posted pictures of an alleged Lion Air maintenance log showing that the aircraft operating Flight JT-610 experienced two technical issues on its previous flight, which were resolved during routine overnight maintenance. The logs indicate that one set of the aircraft’s airspeed and altitude instruments provided inaccurate information shortly after takeoff on the previous flight, and that the aircraft’s elevator controls didn’t feel right. Authorities from the Indonesian government and Lion Air have suggested that the logs shown in the pictures are authentic, however one well-respected aviation journalist has noted that multiple versions of the logs are circulating online, including versions that do not show the corrective maintenance. It is not clear if the technical problem reported by Flight JT-610’s pilots was related to the issues reported in the logs, or if the technical problem on the accident flight played a major role in the crash; there have been several previous accidents where an aircraft experienced technical problems, but the actual cause of the crash was mostly or wholly unrelated to the technical problems.

Data from flight tracking websites such as Flightradar24 suggest that Flight JT-610’s airspeed and altitude were unstable throughout the flight before the aircraft ultimately dived into the ocean. The accuracy of this data is questionable, however. Flight tracking websites’ data comes from the aircraft itself, so erratic airspeed and altitude data could indicate that the aircraft’s own instruments were providing inaccurate information to the pilots. The previous flight operated by the aircraft also showed erratic airspeed and altitude data shortly after takeoff, which could lend credence to the reports of inaccurate airspeed and altitude instruments on the previous flight.

Unreliable instruments can be a serious safety concern, as many aircrafts’ autopilot and flight control systems rely upon airspeed and altitude readings. Instrument failures in poor visibility can cause pilots to become disoriented, which has played a major role in several previous accidents. A report of unreliable instruments can also cause pilots to ignore the instruments that are providing accurate data; this issue has also played a role in several previous crashes. An instrument failure on its own, however, should not cause a crash, and modern airliners have multiple backups for all critical instruments, and have procedures for dealing with unreliable instruments. According to the maintenance logs, the pilots on the Lion Air aircraft’s previous flight correctly diagnosed the instrument issue and used the accurate instruments to safely complete the flight. In July 2018 a Malaysia Airlines (MH) Airbus A330 had all three of its airspeed instruments fail shortly after takeoff due to a botched ground procedure; the pilots returned to the airport and landed safely.


Air Safety in Indonesia

Indonesia has a poor historical safety record, but air safety practices in the country have improved over the past three years. Between 2000 and 2015, Indonesia averaged more than one fatal passenger airliner crash per year, but before the crash of Flight JT-610, Indonesia had gone over three years without a fatal crash on a passenger flight. This improving air safety record has correlated with the Indonesian government’s stronger oversight and regulation of the country’s airlines.

Indonesia’s Directorate General of Civil Aviation (DGCA) is the government body responsible for regulating and overseeing Indonesia’s airlines. Following a series of major crashes, the DGCA failed an audit from the US Federal Aviation Administration (FAA) in 2007, causing the FAA to downgrade Indonesia to Category 2 in the FAA’s International Aviation Safety Assessment (IASA) program, indicating that the DGCA’s oversight of Indonesian airlines did not meet international standards. Shortly afterward, the EU banned all Indonesian airlines from EU airspace. Several Indonesian carriers later passed EU audits and received exemptions from the ban, including Lion Air in 2016.

The DGCA subsequently worked with the FAA, EU, and the UN’s International Civil Aviation Organization (ICAO) to improve its oversight of Indonesian airlines. The effort was successful, and the FAA restored Indonesia’s Category 1 IASA rating in 2016, after the DGCA passed the FAA’s audit. The DGCA also performed well in subsequent audits from ICAO and the EU, and the EU lifted its ban on Indonesian carriers in June 2018.


Lion Air Safety Rating

Lion Air is currently listed as Preferred in the Worldcue Airline Monitor (WAM), but its Preferred status was marginal before the Oct. 29 crash due to the airline’s history of pilot error incidents and Indonesia’s history of poor airline oversight. Lion Air had a high number of pilot error incidents during landings in the mid-2010s and was listed as Not Preferred until 2016. The airline was expanding rapidly at the time, and the high rate of pilot error incidents suggested that the airline was having difficulty finding enough qualified pilots to support its expansion.

In the past two years, however, Lion Air has slowed its growth and taken steps to ensure an adequate supply of qualified pilots, and the airline’s incident rate was improving before to the crash of Flight JT-610. Two key indicators of Lion Air’s progress were its 2016 exemption from the EU’s ban on Indonesian carriers, and its 2017 certification under the International Air Transport Association’s (IATA) IATA Operational Safety Audit (IOSA) program, the most comprehensive global airline safety audit program. The EU’s lifting of its ban on Lion Air caused WorldAware to upgrade Lion Air from its Not Preferred status, but the airline’s Preferred status has remained marginal since then.

In the aftermath of Flight JT-610’s crash, the Australian Department of Foreign Affairs and Trade instructed its officials and contractors to not fly on Lion Air or its subsidiaries Batik Air (ID), Wings Air (IW), Lion Bizjet, Malindo Air (OD), and Thai Lion Air (SL). The instruction was precautionary and was not based on specific information about the cause of Flight JT-610’s crash. US, UK, and Canadian authorities have not made any public statements about prohibiting travel on Lion Air or its subsidiaries as of early Oct. 30.


About the Boeing 737 MAX

Both the aircraft model and the specific airframe involved in Flight JT-610’s crash were very new. The Boeing 737-8 MAX is one of the newest commercial airliner models in the world, and the specific aircraft had been in service for less than three months. It is unclear if the young age of either the aircraft or model played any role in causing the crash.

The Boeing 737-8 MAX is part of the Boeing 737 MAX family, the fourth generation of Boeing 737s. The first 737 MAX entered service in May 2017 with Malindo Air (OD), a subsidiary of Lion Air. Like all modern airliners, the 737 MAX underwent rigorous ground and flight testing before entering service, but has experienced a number of minor technical issues since it began operations. Such “teething issues” are common among new aircraft designs, and almost never pose a safety threat to passengers. In rare cases, however, a combination of these issues and crews’ relative unfamiliarity with a new aircraft model can contribute to an accident. The crash of Flight JT-610 was the first fatal accident involving a 737 MAX; the 737 family as a whole are considered to be safe and reliable aircraft.


What Comes Next

Click on above image for interactive Google Map of Lion Air Flight 610 crash.

Indonesian authorities are currently searching for the main wreckage from Flight JT-610, including the flight’s cockpit voice recorder (CVR) and flight data recorder (FDR), commonly known as the “black boxes.” The wreckage is reportedly in water about 30 meters (98 feet) deep, which is within the capabilities of recovery teams, and the CVR and FDR are likely to be recovered this week. Indonesian authorities have ordered all Indonesian carriers operating the 737 MAX to carry out inspections on the aircraft; it is not clear what specific parts the authorities ordered the carriers to inspect.

The investigation into the crash of Flight JT-610 will likely take at least six months and could take over a year. Indonesian investigators, however, will likely release interim factual reports during the investigation. The first interim report will likely be released after the investigators get all data from the CVR and FDR. In some accidents, these interim reports provide fairly conclusive information regarding the cause of the accident; others provide little useful information. WorldAware will closely monitor the interim reports and any other information from Indonesian investigators for indications regarding Lion Air’s operational and safety standards.

Foreign governments and corporations may follow Australia’s example and restrict travel on Lion Air and its subsidiaries. WorldAware will monitor such developments for any evidence that such restrictions are based on specific safety shortcomings at the airline, not just general precautions.

Several videos claiming to show the crash of Flight JT-610 from inside the passenger cabin are circulating online. These videos are not authentic and are from other incidents where the aircraft landed safely. Further inauthentic videos, photos, and news items are likely to circulate in the aftermath of Flight JT-610’s crash and other future aviation accidents.


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