Monday, September 1, 2008


Relevant Facts leading to the accident
On 07 Mar 2007, Garuda Indonesia flight 200 was being operated on a domestic flight from Jakarta to Yogyakarta (Indonesia). The PIC was also the PF. The PIC intended to carry out an ILS approach to R/W 09 at Yogyakarta, and had briefed for the same. ATC cleared the aircraft for a visual approach, with a requirement to proceed to long final and report runway in sight. Although the crew acknowledged the visual approach clearance, they continued with the ILS approach, without informing the controller. Descent and approach were carried out in VMC. At 10.1 miles (initial fix) from the R/W, the aircraft was at 3927 feet (against an altitude of 2500’, as published in the approach chart) at a speed of 283 kts. The PIC intended to make the FAF (6.6 DME) at the correct altitude and thus carried out a steep descent. This did not permit the speed to wash off at the anticipated rate (a tail wind at this altitude also added to the problem). Speed brakes were not selected. He was aware that it was difficult to make the FAF correctly. Flap 1 was selected and thereafter gear was selected down. The PIC called ‘Check speed, flaps 15’. The copilot called ‘Flaps 5’, as the speed was beyond the flap 15 speed of 205 kts. Flaps 5 were selected. The PIC called for ‘flap 15’ twice but the copilot did not select flap 15 as the speeds were beyond the limits. The PIC called ‘Check speed, flaps 15’ again but the copilot did not select flaps as the speed was beyond 240 kts. Also, he did not apprise the PIC of this fact. During the approach the GPWS alerts and warnings sounded 15 times, and the co-pilot also called for a go-around. The PIC continued the approach with flaps 5, and the aircraft attained glide slope close to R/W 09 threshold. The PIC asked the copilot if the landing checklist had been completed, to which he received no response from the copilot. The aircraft crossed threshold at 232 kts (98 kts faster than the flaps 40 landing speed). Ground speed was 235 kts. The aircraft touched down at 221 kts, bounced twice before settling on the runway. Shortly after touchdown, the copilot called for a go around. The PIC selected thrust reverser and continued with the landing. The aircraft overran the R/W, to the right of the centerline at 110 kts. The aircraft crossed a road, and impacted an embankment before stopping in a paddy field 252 metres from R/W 27 threshold. The aircraft was destroyed by the impact forces and post impact fire. 119 of the total 140 occupants survived the accident.

1. Flight crew communication and co-ordination was less than effective after the aircraft passed 2336’ on descent after flap 1 was selected.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The PIC did not go around when stabilized approach criteria were not met.
3. The PIC did not act on the GPWS warnings, and the two call outs by the copilot to go around. (The PIC was 'fixated' on landing the aircraft - was responding to only one stimuli when there were a host of other stimuli seeking his attention. Happens under stress)
4. The copilot did not follow company instructions to take over control of the aircraft when he saw that the PIC repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training to its B737 flight crews covering vital actions and required responses to GPWS alerts and warnings.

No comments: