October 30, 2018
By Abdul Rahmat Omar
LION Air Flight JT610 went down in the Java Sea 13 minutes after departing from Jakarta. It is very highly unlikely that any of the 189 souls on board had survived.
This tragedy mark’s the 14th incident in Lion Air’s 18 years of operation, an unimpressive air safety record with an average of one incident in every 16 months.
The aircraft that went down was a spanking new Boeing 737-8MAX delivered to the airline last August.
The aircraft first flew on the July 30 2018 and was powered by two CFM International LEAP-1B engines.
However, it suffered from a faulty airspeed indicator during a flight on the night before the fateful flight.
The airline’s engineers claim that the fault had been corrected before the aircraft was allowed to fly. But 12 minutes into the flight the cockpit crew requested to return to base without describing the nature of the emergency it was facing. They never made it back.
While it is still too early to tell for JT610, blocked pitot-static port have contributed to many airliners going down; the previous crash being the Saratov Airlines Antonov An-148 Flight 6W703 on February 11 2018, killing 71 people. It also contributed to the crash of Air France Flight AF477 in the Atlantic Ocean on June 1 2009.
When a static port is blocked, the on-board instruments will give false readings. False readings caused pilots in flights AF447, 6W703, and Birgenair Flight 301 and Aeroperu Flight 603 to react erroneously.
In the case of Flight 603, problem started just two minutes after take-off. There was confusion between the pilots.
Within six minutes, the pilot said: “We don’t have controls. Not even the basics.” The altimeter showed that they were still on the ground, while the three was no airspeed indication.
The above all happened in new generation aircrafts where computers and automation were incorporated to lessen the burden of its flight crew thus increasing the crews’ reliance on automated flight systems.
The FAA has directed airlines to include a blocked pitot tube scenario in simulator trainings to familiarise pilots with the condition.
But how much training is given to pilots? The bare minimum as required by regulations?
Out of the 14 incidents involving Lion Air’s fleet, only four can be attributed to technical errors. The other 10 were due to pilot errors, with wrong flap settings for take-offs and landings, and runway excursions being the top most incidents.
Lion Air, as did most other Indonesian airlines, was once slapped with a ban from the US and European Union’s airspace due to safety concerns. The last Indonesian airlines on the list only had their removal from the list in June of this year.
Indonesia is in the Aviation Safety Network’s list of top 10 countries with the most fatal air accidents – at number nine with 98 fatal accidents that resulted in the deaths of 2,035 people.
How much emphasis is given to the flight crew coordination and conflict management training?
In an incident involving Adam Air Flight 574, the flight crew became too preoccupied with troubleshooting the Inertial Reference System (IRS) that no one was actually flying the aircraft.
When either one of them inadvertently disengaged the autopilot that caused the aircraft to go into a steep bank, both pilots had become spatially disoriented. To add salt to injury, Adam Air’s pilot training syllabus did not cover the failure of the IRS, and neither did any of the pilot receive any training in aircraft upset recovery, including overcoming of spatial disorientation.
The maintenance regime is something that needs a serious look into. In the four incidents involving the technical aspects of Lion Air’s aircrafts, one was when a thrust reverser was not working and caused the deaths of 25 people, one aircraft’s braking system was not at optimum level, one landed without the nose gear down, while the other had fuel pouring out of its tanks due to non-functioning safety valve and overflow detector.
In the case of Flight JT610, the pitot-static port of the aircraft did not function properly during the Jakarta-Denpasar-Jakarta flight the previous night. A technical logbook of the doomed aircraft detailed an “unreliable” airspeed reading on the flight, giving different altitude readings to the pilot and co-pilot – a symptom of blocked pitot-static ports.
Lion Air’s engineering department said that the issue was resolved before the aircraft was allowed to fly the next day. But was it?
The flight reminds me of what happened to Indonesia Air Asia’s Flight QZ8501 in December 2014. Both flights faced technical snags the previous night. Both aircraft were given a clean bill of health by their engineers to fly the next morning. Both aircraft were not brought down by weather.
QZ8501 was brought down, in part, by a cracked solder joint on an electronic card that caused the rudder travel limiter to malfunction. The joint had been repaired several times before instead of being replaced. An action by both pilots, which was not recommended by the aircraft’s manual, was the final nail in the flight’s coffin.
We still don’t know for sure what actually caused Flight JT610 to suddenly drop from the sky into the sea.
Aeroperu Flight 603 flew with blocked pitot-static tubes, that caused faulty data to be transmitted not just to the pilots, but also to the Air Traffic Controller, causing maximum confusion between them.
Spatial disorientation also hit the pilots; they had no idea how high were they flying while the TC told them they were at 10,000 feet, when they were not. In the end, one of the wings struck water and the aircraft crashed into the sea.
The day after the JT610 crash, another flight taking the same route to the same destination showed its altitude upon leaving the shoreline of West Jakarta to be at 16,800 feet at a speed of 370 knots.
JT610’s system transmitted its altitude when passing the same area to be at only 5,100 feet at 318 knots. Its data showed that it was flying at 5,200 feet at 334 knots when the flight crew informed the ATC that it was returning to base.
That they were flying only at 11,600 feet lower than the next day flight in the same area could be an indication of something going wrong. Previous flights all flew higher than 10,000 feet except for the ones that took a right hand turn after departure.
That no emergency was declared when a request to make a turn back was made seemed odd.
Had the pilots declared an emergency then, the ATC would have immediately given the aircraft landing priority and an assigned runway. There was no such request.
Those are the issues that are floating around right now, which can only be answered by the retrieval and processing of both the Cockpit Voice Recorder and Flight Data Recorder. Until then, your guess is as good as mine.