SINGAPORE - Pilot errors, inadequate crew training and lapses in emergency response procedures led to a plane operated by fast-growing budget carrier Lion Air crashing into the sea off Bali in April 2013, according to a final report into the incident.
None of the 108 passengers and crew died in the incident, which took place as heavy rain affected visibility for a Boeing 737-800 on a scheduled flight from Bandung. Four people suffered serious injuries and the aircraft, which had been in service for less than two months with Lion Air, was written off.
The report comes as Lion Air, one of the fastest-growing airlines in the world with hundreds of Airbus and Boeing jets on order, tries to get itself removed from a European Union safety blacklist. The low-cost carrier has suffered eight serious accidents, with six aircraft written off, since January 2002, according to the Aviation Safety Network.
The April 2013 crash occurred as the jet descended rapidly toward the Indonesian island's Ngurah Rai International Airport. The 24-year-old first officer flying the plane at that time was unable to see the runway in the downpour during the descent, according to the report by Indonesia's National Transportation Safety Committee.
The aircraft's pilots disengaged the auto-pilot and flew the plane manually, but they displayed a lack of "situational awareness" as they continued to descend, according to the investigators' report. By the time the 48-year-old captain decided to order a go-around for a second approach to the runway, the aircraft was at an altitude of only 20 feet, the report said. The minimum altitude for a Boeing 737-800 go-around is 50 feet.
Both men, since fired by Lion Air, also failed to adequately follow the airline's operating manual which gave clear instructions on what to do when faced with the situation, according to the report.
Lion Air has since implemented a new policy when it comes to go-arounds, and bolstered training programmes to increase the emphasis on manual flying procedures and pilot monitoring skills.
The report also criticises Lion Air and the flight's cabin crew for poor evacuation skills.
The first officer initially tried to evacuate passengers through a cockpit window. He then used a service door on the right side of the jet when that proved to be unsuccessful, according to the report.
A flight attendant was also unable to detach a life raft. Her only training for this procedure was from watching a video, the report found.