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With Boeing in cross hairs, Lion Air gets a pass on poor safety record

JAKARTA (Indonesia) — When Lion Air Flight 610 took off in clear skies a year ago, the 737 jetliner carried with it an anti-stall system designed by Boeing that would propel the plane into a nose-dive minutes after takeoff, killing all 189 aboard.

With Boeing in cross hairs, Lion Air gets a pass on poor safety record

Indonesian police officers look at belongings of passengers of Lion Air flight JT610 at Tanjung Priok port in Jakarta, Indonesia.

JAKARTA (Indonesia) — When Lion Air Flight 610 took off in clear skies a year ago, the 737 jetliner carried with it an anti-stall system designed by Boeing that would propel the plane into a nose-dive minutes after takeoff, killing all 189 aboard.

But the plane was saddled with another safety burden. Flight 610 was operated by Lion Air, a low-cost Indonesian carrier that has benefited from its political connections to become one of the world’s fastest growing airlines, despite a questionable safety record.

While Boeing has faced intense scrutiny after two fatal crashes in less than five months, Lion Air has escaped similar attention, despite obvious failings that contributed to the disaster of Flight 610.

An investigation by The New York Times, based on interviews with dozens of officials and airline employees, including pilots and members of maintenance teams, found that Lion Air has a track record of working its pilots to the point of exhaustion, faking pilot training certification and forcing pilots to fly planes they worried were unsafe, including the plane that crashed.

Despite making vague promises of improvements after last year’s accident, the air carrier has neither fully acknowledged nor expeditiously addressed the concerns that have been raised about its safety practices, both by government investigators and whistleblowers interviewed by The Times.

“The Boeing issue was an absolute godsend for Lion Air,” said Mr John Goglia, a former member of the US National Transportation Safety Board and an aviation safety expert. “It means Lion Air doesn’t have to deal with what is clearly failure after failure after failure and make the changes needed.”

Of the nine factors that caused the crash according to the final report issued by the Indonesian National Transportation Safety Committee last month, a fatal Boeing design flaw in an automated system was what captured the world’s attention, especially after the crash of another plane in Ethiopia linked to its anti-stall system.

Although the report documented lapses on Lion Air’s part, like shoddy maintenance and undertrained pilots, examples of Lion Air’s culpability were underplayed when the report was presented, dismaying critics who note that Indonesia, the world’s fourth-most populous country, struggles with endemic corruption.

“You get the sense that the raw data that makes Lion look bad is buried in the report for whatever political reasons,” Mr Goglia said.

And Lion Air has not accepted responsibility for the failures listed in the report, and it dismissed most of the safety issues raised to The Times by current and former employees.

In a response attached to the final report, the airline wrote that it was “aware of efforts that have been made to criticise the Lion Air pilots, engineers and maintenance personnel who operated or worked” on the aircraft.

The carrier said “such criticisms are misplaced and should not be considered as contributing factors of the Flight JT610 accident”.

Despite the life-or-death urgency of some of the government report’s safety recommendations, including making improvements to Lion’s hazard-reporting process and its safety training, the company seems to be mulling its next steps, rather than taking immediate, decisive action.

“Give me time,” Mr Daniel Putut, Lion Air’s managing director, said in an interview, when asked how quickly the carrier could implement the recommendations. “Let’s say another one or three months because we need to study it to learn if there are things we need to change.”

“The report,” he added by way of explaining the delay, “is 323 pages long.”

While denying that the deficiencies cited in the report played a part in the crash, Mr Putut said that Lion Air has “tried to improve” how it identifies safety hazards since the disaster. “The accident hurt us so we have done a deep study of our operational safety to prevent something from occurring again,” he said.

At the same time, however, Mr Putut defended Lion Air’s business culture, which critics say prioritises growth over safety.

A former Lion Air chief pilot, Mr Jimmy Kalebos, said that refusing to acknowledge problems was symptomatic of the company’s approach to safety before the crash. That it continues to do so after so many deaths, he added, does not bode well.

“How can you fix a problem,” Mr Kalebos asked, “if you don’t admit it exists?”


In the view of some of the company’s most important employees — its pilots — Lion Air has not taken steps to fix numerous flaws since the crash.

The safety culture at Lion Air has “absolutely not improved,” a pilot said. Like other current and former Lion Air staff members, he agreed to speak only on condition of anonymity to protect his career.

Not a single Lion Air employee has been fired as a result of last year’s accident, according to both government investigators and current and former employees. Mr Putut refused to confirm or deny if anyone had been let go.

Just as the company does not seem pressed to adopt changes from the report (which is actually 322 pages long), Indonesian officials were quick to defend a carrier that has had 11 accidents and incidents since its founding in 1999, according to the Aviation Safety Network.

In comparison, Spirit Airlines, the American low-cost carrier founded in 1980, has suffered two in its history, one in 2002, the other in 2005. Neither was fatal.

What’s more, many additional serious safety lapses at Lion Air were never investigated by the government because the carrier downplayed them or failed to divulge their likely causes, pilots and maintenance workers at the airline said.

In one case in 2016, a Lion Air jet suffered a total loss of engine oil, forcing the pilot to shut down the engine in flight, according to former employees. Yet the Indonesian National Transportation Safety Committee was never called in to investigate.

“What we see in the news is only the visible part of the iceberg,” one pilot said.

But members of the Indonesian government seemed sanguine about the airline’s safety.

“Lion Air maintenance is good,” said Mr Luhut Pandjaitan, a government minister whose portfolio includes oversight of Indonesia’s transportation network. “Lion pilots have no problem. Lion Air facilities are very good.”


Few airline businesses grew as quickly as Lion Air Group, which oversees several carriers in addition to Lion Air. In 1999, Mr Rusdi Kirana started a low-cost carrier with a few rickety jets. By the time of the crash, Lion Air Group had signed deals for 450 brand-new planes from Boeing and Airbus.

On many routes within Indonesia, whose sprawling archipelago makes air travel an everyday necessity, Lion Air was often the only choice, making its peremptory motto oddly appropriate: “We make people fly.”

The Indonesian government has hailed Mr Kirana as a visionary whose company employed 30,000 people. A Christian in a Muslim majority country, Mr Kirana took on a leadership position in an Islamic political party with ties to the government and was named ambassador to Malaysia.

As Lion Air grew, all those new planes needed captains, and the company soon suffered from a dangerous shortage of pilots, according to those who watched the company transform.

In 2016, for example, Lion Air had about 3.5 flight crews (a chief pilot and first officer) for each plane in its fleet, according to company insiders, while the industry norm for airlines operating similar kinds of routes with similar planes is at least twice that.

“Do the math,” said Mr Kalebos, the former Lion Air pilot. “It just doesn’t add up to safety being No 1.”

While that ratio has since improved, according to current and former employees, the conditions for pilots remain onerous.

Under Indonesian law, pilots are not allowed to fly more than 110 hours a month. But faked logs of flying hours were rampant at the company, according to former and current pilots.

Mr Eki Adriansjah, a former chief pilot at Lion who also served as a flight instructor, said he once worked 300 hours in a month and was chided by government regulators.

“I told them, ‘Why are you catching me and not the company?’” he said. “Lion was the one pushing me to work like that.”

Airline representatives denied its pilots were overworked.


Current and former pilots at Lion Air recounted dozens of instances, both before and after the crash, in which they felt pressured to fly, despite concerns about the weather, the plane’s airworthiness or even their own alertness.

In two cases, pilots said they were ordered to fly to airports near where forest fires were raging and smoke obscured visibility.

“The manager told me, ‘Oh, you don’t need to see the runway because we have instruments that can see for you,’” said Eki, the former Lion pilot.

In another case, a Lion Air maintenance crew signed off on a plane as good to go. But the pilot wasn’t confident the plane was fit to fly, and he refused to take off.

Frustrated, a member of the maintenance team contacted a top executive at Lion Air. The pilot soon took to the skies.

Lion Air also had trouble giving its pilots the training necessary to pass a safety audit by the International Air Transport Association, which helps formulate global aviation standards.

Allowing the pilots time for training was hard because the understaffed airline needed them in the air, not in classrooms.

When it became clear that Lion Air would not be able to meet its training targets, a new solution was found, multiple people with the airline at the time said: Faking documentation that training had been conducted.

“Fake certificates and a fake attendance list,” said one pilot who was party to the deception. “Now, magically, the SMS training is compliant on paper,” the pilot added, referring to safety management system training. Lion received its IATA safety certification in 2016.

Mr Putut, the carrier’s managing director, said he was not aware of any falsified paperwork. “I’ve never heard about it, these fake certificates,” he said. “I need to check on that.”


The Indonesian report on the crash notes how the plane experienced problems with speed and altitude readings for several days before the Oct 29 crash.

On the morning of Oct 28, a different flight crew aboard the doomed plane was told to fly it to the island of Bali because an engineer said a fix would be more easily found there.

Friends of the pilot said he was uncomfortable with the decision, given that on the previous leg, the plane had given him highly irregular data readings. But he flew there anyway on the plane that would crash the next day. The pilot did not respond to queries for comment.

“In any other country, making a pilot fly an unsafe plane like that is illegal,” said Mr Goglia, the former National Transportation Safety Board member. “I don’t have words to describe how bad it is.”

At the Bali airport, a vane, known as an angle of attack sensor, was replaced.

Crash investigators were presented with photographs supposedly showing that a mandatory test was done after the vane had been replaced. But upon further inspection, investigators concluded the photos were from a different aircraft.

“This is a test that Lion Air was required to do, and they didn’t,” said Mr John Cox, an aviation safety consultant.

If the test had been done, engineers likely would have realised the vane was calibrated incorrectly by 21 degrees. The misalignment would prove fatal because it mistakenly catalysed Boeing’s anti-stall system, forcing the plane into its final plummet.

No government action has been taken related to the doctored photographs.

Questionable decisions continued after the plane took off from Bali on its next-to-last flight. While in the air, the faulty sensor and the automated anti-stall system kept compelling the plane’s nose down.

But once on the ground in Jakarta late on Oct 28, the flight crew failed to document the full extent of the problems in the plane’s log, 31 pages of which were missing when it was presented to investigators, a breach for which Lion Air was never chided.

As the plane took off on its final flight, the crew of Flight 610 had no idea of all the troubles faced by the pilots a few hours earlier.

“That plane was unairworthy for days,” Mr Goglia said. “It continued to be unairworthy because Lion Air didn’t take proper corrective action. It was an accident waiting to happen, and it happened.” THE NEW YORK TIMES

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