STATUS REKOMENDASI KECELAKAAN PENERBANGAN …

KNKT.15.02.04.04 - PT.

Garuda Indonesia

ATR 72‐600; PK‐GAG

Lombok International

Airport

Republic of Indonesia

03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 1The handling of the aircraft was contrary to the wind condition. The KNKT

recommends that the operator shall emphasized the crosswind handling. OPEN 27-Jan 2020 9-Mar-2017

Chief Pilot ATR has issued notice no. 03/15 and 04/15

date 11 February 2015 to all ATR

Flight Crew regarding “Safety Precaution regarding

event GA7040 at LOP” which contained

key points for a safe and successful crosswind landing.

ATURAN

KNKT.15.02.04.04 - PT.

Garuda Indonesia

ATR 72‐600; PK‐GAG

Lombok International

Airport


03 February 2015

PK-GAG 3-Feb 2015 Final Report 9-Dec 2016 Garuda Indonesia 04 O 2016 4 2

In the preliminary report of this investigation, KNKT issued recommendation

related to standard call out on final. In addition, investigation identified two

change over control of the flight at critical phase of flight without clear

statements. This condition may also extend to the other instructors within

the company. Therefore, KNKT recommends to review the policy of change

over control at critical altitude.

OPEN 27-Jan 2020 9-Mar-2017

VP Flight Operations has issued notice no. 04/15 date

on 9 February 2015 to all Flight Crew.

Chief Pilot ATR has issued notice no. 04/15 date 11

February 2015 to all ATR Flight Crew

regarding “Safety Alertness Regarding Critical Phase of

Flight” which instructed all PiC to

keep maintain situational awareness in all phase of

flight (Approach and Landing) with

follow procedures consistently at 500’ Agl PiC as Pilot

PENGAWASAN

REKOMENDASI (RECOMMENDATION) STATUS

1

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(CLASSIFICATION)TANGGAPAN (RESPONSE)

STATUS REKOMENDASI KECELAKAAN PENERBANGAN (RECOMMENDATION STATUS OF AVIATION OCCURRENCES)

TAHUN 2007 - 2020 (Data s.d Januari 2021)

NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

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(RESPONSE DATE)

NOMOR REKOMENDASI

(RECOMMENDATION NUMBER)

BATAS

WAKTU (DUE

DATE)

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-GAG Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-GAG Final Report.pdf


TANGGAL KEJADIAN

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(ADDRESS TO)

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(AIRCRAFT

REGISTRATION)

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(RESPONSE DATE)

NOMOR REKOMENDASI


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DATE)


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(DATE OF

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ISSUED)

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(ADDRESS TO)

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DATE)


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(ADDRESS TO)

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DATE)


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(DATE OF

OCCURRENCE)

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ISSUED)

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(ADDRESS TO)

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(AIRCRAFT

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DATE)


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(DATE OF

OCCURRENCE)

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(ADDRESS TO)

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REGISTRATION)

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BATAS

WAKTU (DUE

DATE)

KNKT.15.10.21.04 - PT.

Aviastar Mandiri

DHC-6 Twin Otter; PK-

BRM

at coordinate 3° 25'

52.80" S, 120° 4' 12.10"

E

District of Luwu, South

Sulawesi


2 October 2015

PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 34 1 To consider instrument flight training for search and rescue pilots. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN

KNKT.15.10.21.04 - PT.

Aviastar Mandiri

DHC-6 Twin Otter; PK-

BRM

at coordinate 3° 25'

52.80" S, 120° 4' 12.10"

E

District of Luwu, South

Sulawesi

PK-BKA 11-Oct 2015 Final Report 16-May 2016 BASARNAS 04 L 2016 35 1 To consider using drone or unmanned aerial vehicle for air search operation. OPEN 2-Mar 2020 14-Aug-2016 NIL ATURAN

11

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-BKA Final Report (ISBN).pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-BKA Final Report (ISBN).pdf


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DATE)


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(DATE OF

OCCURRENCE)

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ISSUED)

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(ADDRESS TO)

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(INVESTIGATION)

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DATE)


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DATE)


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(DATE OF

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DATE)

KNKT.16.02.05.04 - PT.

Lion Mentari Airline

Boeing 737-900ER; PK-

LFG

Juanda International

Airport, Sidoarjo, East

Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 1

The deteriorating weather condition and difficulty of the SIC to control the

aircraft did not trigger a firm decision, therefore KNKT recommends to review

pilot training program in order to improve pilot decision making.

OPEN 4-Feb 2020 8-May-2017

1. The PIC may change over the control at any time to

ensure that the

highest level of safety is maintained. (OM-A8.3.1.5.3)

2. Pilot Decision Making Concept is part of CRM

training Syllabus on

Pilot program training in Operation Training Manual

(OM D 5.3.8)

3. Initial Training/Mandatory Training (OM-D 5.2.2)

4. Upgrading Training/Command Training (OM-D 5.2.6)

5. Re-Qualification Training (OM-D 5.2.7)

6. Recurrent Training, included on Recurrent/LOFT (OM-

PENGAWASAN

KNKT.16.02.05.04 - PT.

Lion Mentari Airline


LFG

Juanda International

Airport, Sidoarjo, East

Java


20 February 2016

PK-LFG 20-Feb 2016 Final Report 7-Feb 2017 Lion Air 04 O 2017 5 2

During manual flying, the SIC had difficulty to control the aircraft that was

indicated by the activation of EGPWS hard alert ‘GLIDE SLOPE, GLIDE SLOPE’,

therefore KNKT recommends to review the procedure regarding the use of

autopilot and pilot training program in order to improve manual flying skill.

OPEN 4-Feb 2020 8-May-2017

1. Initial Training Lesson Plan

2. Line Training Lesson Plan (OTM 5.5.17)

3. Annual line check

PENGAWASAN

17


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

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(AIRCRAFT

REGISTRATION)

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(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

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(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

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(AIRCRAFT

REGISTRATION)

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(RESPONSE DATE)

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BATAS

WAKTU (DUE

DATE)

KNKT.16.04.07.04 -

Batik Air Indonesia and

TransNusa Aviation

Boeing 737-800 (PK-LBS)

and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma

International Airport,

Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 1

It is recommended that the operator enhances the FCTM chapter 3.24

Rejected Takeoff Decision which is the PIC should announce the abnormality

simultaneously.OPEN 4-Feb 2020 9-Jul-2017

Operation Directorate revised the Operation Manual A

8.3.2.2.4 Rejection of Take-Off. (Appendix B)ATURAN

KNKT.16.04.07.04 -

Batik Air Indonesia and

TransNusa Aviation

Boeing 737-800 (PK-LBS)

and ATR 42-600 (PK-

TNJ)

Halim Perdanakusuma

International Airport,

Jakarta


4 April 2016

PK-LBS & PK-TNJ 4-Apr 2016 Final Report 10-Apr 2017 Batik Air 04 O 2017 7 2

It is recommended that the operator to review the evacuation procedure and

consider the area can be observed through the viewing windows. OPEN 4-Feb 2020 9-Jul-2017

Operation Directorate revised SEP 1.4.5. Manual

regarding principles before opening exit(s) and warning

signals fligh crew to flight attendants on SEP 1.4.3.1

(Appendix C)

PENGAWASAN

18

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LBS and PK-TNJ Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LBS and PK-TNJ Final Report.pdf


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

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(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

19

KNKT.16.04.09.04 -

Global Aviation Flying

School

Cessna 172 G, PK-TGL

Budiarto Airport,

Tangerang


28 April 2016

PK-TGL 28-Apr 2016 Final Report 12-May 2017Global Aviation

Flying School04 O 2016 9 1

To introduce the student pilots with Approach and Landing Accident

Reduction (ALAR) training and stabilize approach criteria and to emphasized a

go around shall be made when does not meet the criteria.

CLOSED 18-Feb 2020 10-Aug-2017

The Global Aviation Flying School conducted safety

briefing to all pilot about Approach and Landing

Accident Reduction (ALAR) using ALAR toolkit from

Flight Safety Foundation.

ATURAN

20

KNKT.16.05.10.04 -

PT.LION MENTARI

AIRLINES ; AIRBUS A330

& B737-800 ;

SOEKARNO-HATTA

AIRPORT ; 1 MAY 2016

PK-LEF & PK-LJR 1-Apr 2016 Final 8-Jun 2018 Lion Air 04 O 2018 10 1

The aircraft LNI077 was taxi in the narrow area and no ground assistance

provided to the pilot, therefore KNKT recommends to consider to stop or

request ground assistance during taxi in narrow area.

OPEN 4-Feb 2020 6-Sep-2018

1. Conduct re-training to flight crew with summary

2. Operation published company Internal Notam

(INTAM)

3. Safety & Security Directorate has been conducted

Risk Management

(14/RMR/VI/2016)

4. Safety & Security Directorate has been published

Safety Information

to All pilot (07/SS/SINF/V/2016)

ATURAN

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 09 PK-TGL Short Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2016 - 010 - PK-LEF and PK-LJR Final Report.pdf


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

KNKT.17.08.25.04 -

PT. Lion Airlines dan

PT. Wings Abadi Airlines


LJZ dan ATR 72-500;PK-

WFF

Kulanamu International

Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 6The KNKT recommends to ensure air traffic controllers consider the possible

hazard when using RET for departure aircraft. CLOSED 7-Feb 2020

The AirNav Indonesia amended the ATS SOP for

Aerodrome Control Tower to include detail procedure

to use of Rapid Exit Taxiway (RET) as follows:

If controller will use RET for departure traffic, the

controller must consider:

- The use of RET will expedite and avoid delay, or to

optimize the use of runway;

- The remaining runway is sufficient for aircraft to

takeoff;

- No aircraft conducts landing approach on long

final/final/inbound heading; and

- No objection from pilot to use RET for takeoff.

The procedure for using RET for departure is as follows:

- Controller must advise the remain runway length to

the pilot;

- The use RET on opposite runway condition is

prohibited; and

- The use of conditional phrase/clearance is prohibited.

PENGAWASAN

KNKT.17.08.25.04 -

PT. Lion Airlines dan

PT. Wings Abadi Airlines


LJZ dan ATR 72-500;PK-

WFF

Kulanamu International

Airport, Medan -


3 August 2017

PK-LJZ dan PK-WFF 3-Aug 2017 Final 9-Apr 2018 AirNav Indonesia 04 A 2017 25 7The KNKT recommends to review the ATS SOP to include detail procedure or

guideline for air traffic controller.OPEN 7-Feb 2020

The AirNav Indonesia amended the ATS SOP for

Aerodrome Control Tower including the prohibition to

use the use of conditional phrase/clearance is

prohibited.

ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan

Penerbangan04 L 2017 10 3

The KNKT recommend the Aviation Medical Center to conduct the required

examination including ECG resting or ECG exercise in accordance with the

CASR part 67.

CLOSED 29-Jan 2020 24-Aug-2019

The Aviation Medical Center had developed an

integrated online medical record application which

included the exercises need to be completed based on

CASR part 67 as a default step to be completed in the

application. Special issuance for pilots who could not

performed or does not meet the requirement and

standard for ECG resting or exercise, shall be discussed

in Medical Review Board for further evaluation

ATURAN

KNKT.17.04.10.04 - PT.

Spirit Avia Sentosa

(FlyingSAS); Cessna

2018; PK-FSO; Anem

Mountain, Oksibil

Papua

PK-FSO 12-Apr 2017 Final 26-May 2019Balai Kesehatan

Penerbangan04 L 2018 10 4

The KNKT recommend the Aviation Medical Center to conduct examiner

workload analysis to adjust the ration of examiner and applicant so that the

examination can be performed thoroughly.

CLOSED 29-Jan 2020 24-Aug-2019

The Aviation Medical Center (AMC) had reviewed the

ratio between examiner and their workload, and

conducted workload analysis. The result of the analysis

was the AMC need 11 examiners. After the accident,

the AMC had added 5 examiners and currently had 15

examiners in total.

ATURAN

33

34

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LJZ & PK-WFF Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/PK-LJZ & PK-WFF Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 010 - PK-FSO Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 010 - PK-FSO Final Report.pdf


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

KNKT.17.11.33.04 - PT.

Wings Abadi Airlines &

BP3 Banyuwangi - ATR

72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 1The KNKT recommend to AirNav Indonesia to ensure air traffic controller

provides all necessary information to the accepting unit as stated in the SOP.CLOSED 7-Feb 2020

The AirNav Indonesia developed Rating Examination

Guidelines for Air Traffic Controller which included:

- 8 hours classroom briefing session to rehears

technical knowledge of air traffic control, including the

procedure of coordination with the adjacent units;

- theoretical check based on the classroom session

material;

- practical check during daily duty which included the

coordination procedures of information transfer and

update methods.

PENGAWASAN

KNKT.17.11.33.04 - PT.

Wings Abadi Airlines &

BP3 Banyuwangi - ATR

72-212A & CESSNA 172S

Near point NAMP

ISLAND, NTB

21 November 2017

PK-WHS & PK-BYK 21-Nov 2017 Preliminary Report 29-Dec 2017 Airnav Indonesia 04 A 2017 33 2The KNKT recommend to AirNav Indonesia to ensure air traffic controller

maintain listening watch to all communication.CLOSED 7-Feb 2020

The AirNav Indonesia developed Rating Examination

Guidelines for Air Traffic Controller which included:

- 8 hours classroom briefing session to rehears

technical knowledge of air traffic control, including the

requirement to maintain the listening watch;

- theoretical check based on the classroom session

material;

- practical check during daily duty which included the

requirement to maintain the listening watch.

The AirNav Indonesia conducted technical briefing for

all personnel before their duty which included the

PENGAWASAN

KNKT.18.01.01.04; PT.

Batik Air Indonesia dan

PT. Lion Mentari

Airlines; Airbus A320-

200 dan Boeing 737-

900ER; Near Waypoint

Tirus Surabaya, East of

Java

PK-LUI & PK-LFP 6-Jan 2018 Final 24-Jul 2018 Batik Air 04 O 2018 1 1

The duty and flight hour of both pilot did not exceed the requirement of the

OM – Part A however, the slip of altitude clearance between the pilot mind

and the readback, the ability to monitor the other traffic communication and

feeling sleepy were indications of pilot fatigue. The fatigue might be caused by

overnight flight which increasing of potential fatigue was not fully recovered,

and the condition of the pilots woke up in early morning might reduce the

time for recovery sleep

Therefore, KNKT recommends the Batik Air to establish fatigue risk

management which may refer to ICAO Annex 6 and ICAO Document 9966.

OPEN 4-Feb 2020 22-Oct-2018

Operation Directorate revised the operation

administrative manual regarding operational planning

process to include the acclimatization.

The Safety Security and Quality Directorate published

the Quality Assurance Recommendation regarding

fatigue Risk Management Plan addressing Batik Air

Management.

ATURAN

38

KNKT,18,04,09,04 ;

PT.LION MENTARI

AIRLINES ; B737-900ER ;

ON ROUTE JAKARTA TO

JAMBI

PK-LFK 1-Apr 2018 Preliminary Report 8-Jun 2018 Lion Air 04 O 2018 9 1Improve the pilot training to ensure pilot understanding to the aircraft system

and performs procedure properly.OPEN 4-Feb 2020 6-Sep-2018

1. Lion Operational Training Department has been

revised syllabus

B737NG Recurrent (LOFT) 4, Issued 01 revision 01, 25

July 2018

‐page 9: MEL Discussion 21 – 01 ‐1c Air‐condition Packs

(-900/-

900ER) objective: trainee understand how to read and

when to set

ATURAN

35

36

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 033 - PK-WHS & PK-BYK Final Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/2017 - 033 - PK-WHS & PK-BYK Final Report.pdf

//192.168.0.9/../00 Investigation Data/2018/001 PK-LUI & PK-LPF 06012018 - AirProx/Correspondence/OUT/Draft Final Report/PK-LUI & PK-LPF Draft Final Report .pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 009 - PK-LFK Preliminary Report.pdf


TANGGAL KEJADIAN

(DATE OF

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NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

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ISSUED)

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(ADDRESS TO)

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NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

KNKT.18.10.35.04 PT.

Lion Mentari Airlines;

Boeing 737-8 MAX;

Tanjung Karawang,

West Java; 29 October

2018

PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 1

Refer to the CASR Part 91.7 Civil Aircraft Airworthiness and the Operation

Manual part A subchapter 1.4.2, the pilot in command shall discontinue the

flight when un-airworthy mechanical, electrical, or structural conditions occur.

The flight from Denpasar to Jakarta experienced stick shaker activation during

the takeoff rotation and remained active throughout the flight. This condition

is considered as un-airworthy condition and the flight shall not be continued.

KNKT recommend ensuring the implementation of the Operation Manual part

A subchapter 1.4.2 in order to improve the safety culture and to enable the

pilot to make proper decision to continue the flight.

CLOSED 4-Feb 2020 26-Feb-2019

1. Lion Air had emphasized the Operation Manual part

A (OM-A) Chapter 1.4.2.

2. Lion Air had issued the Safety Notice

16/SS/SN/XI/2018 Lion Emergency Flowchart-Revision

Nov 2018.

3. Lion Air had issued Temporary Revision (TR) on

Safety Management Manual (SMSM) Number

01/ERM/XI/2018 on Lion Emergency Flowchart.

4. Short term: Flight Operation had published NTP

30/NT/XI/2018 Flight Following OM-A 236 to all pilot

regarding OM 2.3.6 (Flight Following).

5. Lion Air had issued LA-OT-02-PILOT-02-11 B737

Recurrent 5 Trainee Lesson Plan.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Preliminary Report 28-Nov 2018 Lion Air 04 O 2018 35 2

According to the weight and balance sheet, on board the aircraft were two

pilots, five flight attendants and 181 passengers consisted of 178 adult, one

child and two infants. The voyage report showed that the number of flight

attendant on board was six flight attendants. This indicated that the weight

and balance sheet did not contain actual information.

KNKT recommend ensuring all the operation documents are properly filled

and documented.

CLOSED 4-Feb 2020 26-Feb-2019

1. Lion Air had coordinated with Angkasa Aviation

Services (AAS) and they had issued Quality Assurance

Notice 102/AQ-AAS/N/XII/2018 on Akurasi Konfigurasi

Crew di Pesawat.

2. Chief Pilot had published Notice to Pilot

010/NTP/II/2019 SAFETY and SERVICE IMPROVEMENT

regarding cross check crew composition with Flight

Attendant and Ramp officer.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 3KNKT recommends establishing system to ensure the company manuals are

updated in timely manner.CLOSED 4-Feb 2020 23-Jan-2020

3. To ensure the company manual are updated in

timely manner:

- Lion Air has been revised COM 6.4.6.1 regarding

Document Review

(TR 11/TR/COM-JT/XII/2019)

- Lion Air has been publishing notice: QAN-

05/DQ/XII/2019: Manual Synchronization

ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 4KNKT recommends that Lion Air review the SMS training material and the

duration of trainingCLOSED 4-Feb 2020 23-Jan-2020

1. Lion Air has been revised SMS training syllabus:

-Initial [LA-SS-03-01-54] Rev 2 2019

Recurrent [LA-SS-03-01-55] Rev 2 2019

Material:

-Initial [LA-SS-03-01-49] Rev 7 2019

Recurrent [LA-SS-03-01-52] Rev 2 2019

Revision of SMSM related 7.4.2 General safety

Management System Training (TR 1/SMSM/XII/2019).

2. Lion Air has been revised duration of SMS training.

3. Lion Air has been inserted Training case of JT43 and

PENGAWASAN

45

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 035 - PK-LQP Preliminary Report.pdf

http://knkt.dephub.go.id/knkt/ntsc_aviation/baru/pre/2018/2018 - 035 - PK-LQP Preliminary Report.pdf

//192.168.0.9/../01 FINAL REPORT Published per year/2019/2018 - 033 - PK-LQP Final Report.pdf



TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Lion Air 04 O 2018 35 5recommends that Lion Air improve their hazard report management enabling

identifying the hazard and provides proper mitigation.CLOSED 4-Feb 2020 23-Jan-2020

To improve Lion Ops Personnel knowledge regarding

hazard identification:

-Lion Air has been published Monthly Bulletin edition

Nov 2019 vol 58, add content example of hazard report

from CORUSON (continue program to next edition)

-Lion Air has been conducted safety campaign

regarding hazard identification and hazard reporting:

station SOC (24 July 2019), station JOG (25 July 2019),

CGK (16 August 2019 FMM Management (11 July

2019), ME 121 (2 Dec 2019)

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 AirNav Indonesia 04 A 2018 35 9KNKT recommends providing information to the flight crew that the altitude

indication on the ATC radar display was repeating data from the aircraftCLOSED 8-Jan 2020 23-Jan-2020

AirNav Indonesia issued circular to all branch office

which contained instruction to review and amend the

Standard Operation Procedure for ATS to include:

1. Information that pressure-altitude-derived level

information of aircraft on the situational display (radar

display) is come from aircraft.

2. Additional phraseology to be used by air traffic

controller when responding pilot question of their

aircraft altitude, as follows: ALTITUDE/LEVEL

INDICATION IS REPEATING DATA FROM YOUR

AIRCRAFT, YOUR ALTITUDE/LEVEL (altitude/level).

ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Xtra Aerospace 04 MO 2018 35 10

KNKT recommends emphasizing the implementation of a company manual

including equivalency assessment, training and written procedure, to ensure

component being repaired are properly maintained

TDTL 17-Jan 2020 23-Jan-2020

On 24 October 2019 the company surrendered its

repair station certificate and no longer performs

component maintenance or otherwise exercises the

privileges of a repair station. Accordingly, there is no

need for Xtra to take any further actions.

PENGAWASAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 11

KNKT recommends that the aircraft manufacture to consider the effect of all

possible flight deck alerts and indications on flight crew recognition and

response; and incorporate design, flight crew procedures, and/or training

requirements where needed to minimize the potential for flight crew actions

that are inconsistent with manufacturer assumptions

CLOSED 1-Dec 2020 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 12KNKT recommends that Boeing include a larger tolerance in the design is

required to allow operability by a larger population of flight-rated pilotsCLOSED 1-Dec 2020 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 13

KNKT recommends that Boeing and the FAA more closely scrutinize the

development and certification process for systems whose malfunction has the

ability to lead to loss of control of the airplane.

CLOSED 1-Dec 2020 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 14KNKT recommends to Boeing to develop the guidance for the criteria of

information which should be included in flight crew and engineer’s manualsCLOSED 1-Dec 2020 23-Jan-2020 ATURAN

KNKT.18.10.35.04 PT.


Boeing 737-8 MAX;

Tanjung Karawang,


2018

PK-LQP 29-Oct 2018 Final 25-Oct 2019 Boeing Company 04 M 2018 35 15KNKT recommends to Boeing that they ensure that certified and delivered

airplanes have intended system functionalityCLOSED 1-Dec 2020 23-Jan-2020 PENGAWASAN

45










TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)


TANGGAL KEJADIAN

(DATE OF

OCCURRENCE)

SUMBER (SOURCE)

TANGGAL


ISSUED)

INSTANSI PENERIMA

(ADDRESS TO)

KATEGORI




NOINVESTIGASI

(INVESTIGATION)

REGISTRASI PESAWAT

(AIRCRAFT

REGISTRATION)

TANGGAL DITERIMA

(RESPONSE DATE)

NOMOR REKOMENDASI


BATAS

WAKTU (DUE

DATE)

JUMLAH 241

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