KOMITE NASIONAL KESELAMATAN TRANSPORTASI REPUBLIC OF INDONESIA FINAL KNKT.18.10.35.04 Aircraft Accident Investigation Report PT. Lion Mentari Airlines Boeing 737-8 (MAX); PK-LQP Tanjung Karawang, West Java Republic of Indonesia 29 October 2018 2019 This Final Report is published by the Komite Nasional Keselamatan Transportasi (KNKT), Transportation Building, 3rd Floor, Jalan Medan Merdeka Timur No. 5 Jakarta 10110, Indonesia. The report is based upon the investigation carried out by the KNKT in accordance with Annex 13 to the Convention on International Civil Aviation, the Indonesian Aviation Act (UU No. 1/2009) and Government Regulation (PP No. 62/2013). Readers are advised that the KNKT investigates for the sole purpose of enhancing aviation safety. Consequently, the KNKT reports are confined to matters of safety significance and may be misleading if used for any other purpose. As the KNKT believes that safety information is of greatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging the KNKT as the source. When the KNKT makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the KNKT fully recognizes that the implementation of recommendations arising from its investigations will in some cases incur a cost to the industry. Readers should note that the information in KNKT reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability. Jakarta, October 2019 KOMITE NASIONAL KESELAMATAN TRANSPORTASI CHAIRMAN SOERJANTO TJAHJONO Dedicated to those who lost their lives in this accident, their families and relatives their sacrifice will not be in vain they will be forever be missed and never forgotten i to our beloved teacher, colleague and friend Prof. Dr. Ir. Mardjono Siswosuwarno 17 May 1948 – 20 September 2019 this will not be your last contribution ii TABLE OF CONTENTS TABLE OF CONTENTS ..................................................................................................... iii TABLE OF FIGURES ....................................................................................................... viii ABBREVIATIONS AND DEFINITIONS ........................................................................... x SYNOPSIS ......................................................................................................................... xviii 1 FACTUAL INFORMATION ....................................................................................... 19 1.1 History of the Flight............................................................................................. 19 1.2 Injuries to Persons................................................................................................ 28 1.3 Damage to Aircraft .............................................................................................. 28 1.4 Other Damage ...................................................................................................... 28 1.5 Personnel Information ......................................................................................... 28 1.5.1 Captain .................................................................................................... 28 1.5.2 First Officer (FO) ................................................................................... 29 1.5.3 Flight Attendants .................................................................................... 31 1.5.4 Air Traffic Controller ............................................................................. 31 1.6 Aircraft Information............................................................................................. 32 1.6.1 General ................................................................................................... 32 1.6.2 Engines ................................................................................................... 33 1.6.3 Recorded Aircraft Problems ................................................................... 33 1.6.4 Angle of Attack (AOA) Sensors Historical Record ............................... 37 1.6.4.1 Removed Angle of Attack sensor (P/N 0861FL1; S/N 21401) ................................................................................... 37 1.6.4.2 Installed Angle of Attack (AOA) sensor (P/N 0861FL1; S/N 14488) ............................................................................ 37 1.6.5 Aircraft System information ................................................................... 38 1.6.5.1 Air Data Inertial Reference System ...................................... 38 1.6.5.2 Angle of Attack (AOA) Sensors ........................................... 43 1.6.5.3 Horizontal Stabilizer ............................................................. 46 1.6.5.4 MCAS Functional – Detailed Description ............................ 48 1.6.5.5 Autopilot System and Flight Director (F/D) ......................... 50 1.6.5.6 Auto-throttle (A/T) System ................................................... 51 1.6.5.7 Stall Warning System ........................................................... 52 1.6.5.8 AUTO BRAKE DISARM Amber Light ............................... 53 1.6.5.9 Take Off Configuration Warning Light ................................ 53 iii 1.6.5.10 Enhanced Ground Proximity Warning System (EGPWS): Bank Angle Alert .................................................................. 54 1.6.5.11 Air Traffic Controller (ATC) Transponder ........................... 54 1.6.6 Boeing 737-8 (MAX) Fault Handling System ....................................... 55 1.6.6.1 IAS Flag Fault Isolation and Rectification Procedure .......... 57 1.6.6.2 ALT Flag Fault Isolation and Rectification Procedure ......... 59 1.6.6.3 IAS Disagree Fault Isolation and Rectification Procedure ... 59 1.6.6.4 ALT Disagree Fault Isolation and Rectification Procedure .. 61 1.6.6.5 Angle of Attack failure ......................................................... 62 1.6.6.6 AOA Disagree Fault Isolation and Rectification Procedure . 62 1.7 Meteorological Information ................................................................................. 64 1.8 Aids to Navigation ............................................................................................... 66 1.8.1 ABASA 1C ............................................................................................. 66 1.8.2 Automatic Dependent Surveillance – Broadcast .................................... 66 1.9 Communications .................................................................................................. 67 1.10 Aerodrome Information ....................................................................................... 67 1.11 Flight Recorders................................................................................................... 67 1.11.1 Digital Flight Data Recorder (DFDR) .................................................... 67 1.11.2 Cockpit Voice Recorder ......................................................................... 79 1.12 Wreckage and Impact Information ...................................................................... 85 1.13 Medical and Pathological Information ................................................................ 86 1.14 Fire ....................................................................................................................... 86 1.15 Survival Aspects .................................................................................................. 87 1.16 Tests and Research .............................................................................................. 87 1.16.1 Installation Test AOA Sensor with Known Bias .................................... 87 1.16.2 Observation to the Xtra Aerospace ........................................................ 89 1.16.3 Engineering Simulator ............................................................................ 91 1.17 Organizational and Management Information ..................................................... 94 1.17.1 Aircraft Operator .................................................................................... 94 1.17.1.1 Operation Manual (OM)-part A ............................................ 94 1.17.1.2 Operation Training Manual ................................................... 98 1.17.1.3 Flight Crew Operations Manual (FCOM) ........................... 100 1.17.1.4 Flight Crew Training Manual (FCTM) ............................... 101 1.17.1.5 Quick Reference Handbook (QRH) .................................... 104 iv 1.17.1.6 Fault Reporting Manual (FRM) .......................................... 118 1.17.1.7 Minimum Equipment List ................................................... 118 1.17.1.8 Safety Management System Manual .................................. 119 1.17.1.9 Lion Air Maintenance Management ................................... 123 1.17.2 Approved Maintenance Organization .................................................. 135 1.17.2.1 Batam Aero Technic (BAT) Management .......................... 135 1.17.2.2 Defect Handling .................................................................. 137 1.17.2.3 On-Board Maintenance Function (OMF) Handling ........... 138 1.17.2.4 BAT Repetitive Problem Handling ..................................... 138 1.17.3 Xtra Aerospace LLC ............................................................................ 140 1.17.4 Minimum Equipment List Regulations