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B732, Pekanbaru Indonesia, 2002

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Summary
On 14 January 2002, a Boeing 737-200, operated by Lion Air, attempted to complete a daylight take off from Pekanbaru, Indonesia without flaps set after a failure to complete the before take off checks. The rejected take off was not initiated promptly and the aircraft overran the runway. The take off configuration warning failed to sound because the associated circuit breaker was so worn that it had previously auto-tripped and this had not been noticed.
Event Details
When January 2002
Actual or Potential
Event Type
Human Factors, Runway Excursion
Day/Night Day
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-200
Operator Lion Air
Domicile Indonesia
Type of Flight Public Transport (Passenger)
Origin Pekanbaru
Intended Destination Batam
Take off Commenced Yes
Flight Airborne No
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport Pekanbaru
General
Tag(s) Inadequate Airworthiness Procedures,
Inadequate Aircraft Operator Procedures
HF
Tag(s) Ineffective Monitoring,
Violation,
Procedural non compliance
RE
Tag(s) Overrun on Take Off,
RTO decision after V1,
Unable to rotate at VR
EPR
Tag(s) Emergency Evacuation,
Slide Malfunction
CS
Tag(s) Evacuation on Cabin Crew initiative
AW
System(s) Equipment / Furnishings,
Indicating / Recording Systems,
Emergency Evacuation
Contributor(s) OEM Design fault,
Component Fault in service
Safety Net Mitigations
Malfunction of Relevant Safety Net No
Stall Protection Available but ineffective
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Non-aircraft damage Yes
Injuries Few occupants
Causal Factor Group(s)
Group(s) Aircraft Operation,
Aircraft Technical
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 14 January 2002, a Boeing 737-200 being operated by Lion Air on a domestic scheduled passenger fight from Pekanbaru to Batam could not get airborne from Runway 18 at Pekanbaru when rotated and a rejected take off as made which led to an overrun recorded as between 240 and 275 metres and impact with trees. The aircraft was destroyed but there was no fire and all 102 occupants were able to evacuate with only one serious injury sustained.

Investigation

An Investigation was carried out by the Indonesian NTSC. Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data were successfully replayed with the exception of the absence of the cockpit area microphone channel which had no data. The FDR was of limited value as it was designed to record only 11 parameters.

It was established that an engineer had been occupying the flight deck supernumerary seat, that the First Officer had been PF and that a reduced thrust take off was being made. Runway 18, which is 2150 metres long, was used for the take off. When the aircraft did not become airborne following rotation to the prescribed attitude, and the stick shaker was reported to have activated, the initial response of the aircraft commander had been to increase the thrust. When this did not produce the expected effect, a rejected take off had been initiated with aircraft around 25 knots46.3 km/h
12.85 m/s
above V1. An overrun followed during which the aircraft was steered around obstructions.

A review of the available evidence led to the conclusion that the take off had been attempted without correct configuration of the wing - with the trailing edge flaps and leading edge slats stowed. It was noted that the TOWS had not activated and that “The examination on the aural warning CB shows that the CB can not latch in due to wear on the latching mechanism. Such wear should be remedied by replacing the CB. This, however, was not done. Instead, for some reason, the maintenance of the previous owner/operator installed pull-out guard on the CB. Such failure to understand the problem contributes to the accident.”

Other findings related to an inadequately secured galley cart which broke loose during deceleration and obstructed the exit from the flight deck into the passenger cabin and a failure of the rear right slide to deploy. Because the left hand side of the aircraft at rest had been deemed too high above the ground for use of left hand side exits by the cabin crew who had also believed that they had seen smoke (rather than the probable dust from the terrain) in the vicinity of the forward right hand exit, the evacuation had been completed almost entirely by use of the single right side over wing exit.

The Investigation concluded that:

“Since there is no indication that flaps system failure or flap asymmetry contributes in the failure of flap to travel to take-off configuration, the most probable cause for the failure is the improper execution of take-off checklist. Failure of the maintenance to identify the real problem on the aural warning CB, causes the CB to open during the accident and therefore is a contributing factor to the accident.”

The Final Report KNKT/02.01/03.03.011 was published on 1 February 2003 and contained 9 Safety Recommendations as follows:

That the Directorate General of Air Communications:

  • Ensure that the trolley stowage in the cabin were strong enough so that the trolley would not lose easily.
  • Ensure that the escape slides on the airplane function and certified properly.
  • Ensure that the number of flight and cabin crews are sufficient with the number of aircraft in the fleet.
  • Re-evaluate the emergency training of PT Lion Air as accordance to CASR 121.717 Crew Member Emergency training.

That Lion Air:

  • Emphasize the checklist and standard call outs procedures for all pilots.
  • Perform Crew Member Emergency Training (for) the crew (in) accordance (with) the company’s and manufacturing company’s manual.
  • Identify and record the cause of (any) special modification, such as pull out guard on the aural warning CB. Should the operator (have) any doubt, it should question the previous owner, the manufacturer, or the authority.
  • Ensure that the escape slides on the airplane function and certified properly.

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