The final report by Indonesia’s National Transportation Safety Committee (NTSC) on the April 13, 2013 crash of a Lion Air Boeing 737 in Bali cited the airliner’s pilots and their loss of situational awareness as the primary cause of the accident. Four people were seriously injured when the aircraft crashed into water just short of the runway although no lives were lost.

Investigators found fault in the pilot-in-command (PIC) for continuing an instrument approach below minimums when both pilots had lost sight of the runway environment. The second-in-command (SIC)–the pilot initially flying the approach–flagged up this lack of situational awareness to the captain at two different times during the final moments of the approach. The SIC disengaged the autopilot and autothrottles at minimums but continued the approach below minimums, apparently because the PIC said he saw the runway end flashing lights.

The captain later told investigators that he took control of the aircraft from the SIC and decided to continue the approach past minimums because he expected to break through a band of rain into the clear in sufficient time to safely land the aircraft.

The report said, “at 150 feet agl, the SIC called that he could not see the runway, but the approach was continued until after the enhanced ground proximity warning system called ‘twenty [feet].’”

In the final moments before impact and after autopilot disengagement the Boeing’s rate of descent increased to as much as 1,136 feet per minute. The captain issued a “go-around” command one second before impact.