Pilot blamed for Garuda crash

[Ben Longden]

• Melb Age
   
   
  

 

 

October 22, 2007 - 5:07PM

 

The chief pilot of a plane that crashed in Indonesia, killing five Australians and 16 other people, ignored 15 alarm bells as the plane came in to land too quickly, a report has found.

 

The Boeing 737 exploded into flames in a rice field after skidding off the end of the runway in Yogyakarta, Central Java on March 7.

 

Investigators have scoured the plane's black box cockpit voice recorder and data log for clues to the disaster.

 

The final report stemming from the crash investigation found the pilot had landed, despite a flood of warnings.

 

"During the approach, the Ground Proximity Warning System (GPWS) alerts and warnings sounded 15 times, and the copilot called for the pilot in command to go around," the report found.

 

"The aircraft was flown at an excessive air speed and steep flight path angle during the approach and landing, resulting in an unstabilised approach.

 

"The pilot in command did not follow company procedures that required him to fly a stabilised approach, and he did not abort the landing and go around when the approach was not stabilised.

 

"His attention was fixated or channelised on landing the aircraft on the runway and he either did not hear, or disregarded the GPWS alerts, and warnings, and calls from the copilot to go around."

 

The investigation also found the copilot did not follow company procedures and take control of the plane when he saw the pilot repeatedly ignore the alerts and warnings.

 

Garuda records also showed no evidence that the pilots had been trained to respond appropriately to the warnings.

 

The investigation also found Yogyakarta airport's fire fighting service was unable to reach the accident site and some vehicles lacked necessary equipment.

 

"The delay in extinguishing the fire, and the lack of appropriate fire suppressant agents, may have significantly reduced survivability," the report said.

 

"The airport emergency plan and its implementation were less than effective."

 

National Transport Safety Committee chairman Tatang Kurniadi said the report was aimed a preventing further accidents, and was not to be used as the basis for any legal action over the March crash.

 

Kurniadi said the committee would not (not) hand over any evidence gained from the plane's flight recorders, to help the police investigation.

 

Police are continuing to investigate the crash and have interviewed the pilots, who survived by scrambling out of the cockpit.

 

"I would like to go back to the objective of this, the report was made by NTSC for safety purposes only, not for blaming,'' he said.

 

"If any institution wants to ... follow up that accident, that's their own decision."

 

He said the committee's report could not be used for legal purposes.

 

"The report contained the results from the cockpit voice recorder and flight data recorder, but according to international regulations on aviation these black boxes are not allowed to be used for ... liability purposes," Kurniadi said.

 

"We will not give police or any institution (information) other than for safety purposes only - it's in international regulations and we want to follow those regulations."

 

AAP

 

 

[Yenn]

One sure outcome of this is that we will all think very seriously about flying with an Indonesian airline.

 

I havn't flown Garuda but did fly with an internal line a few years ago and was not impressed. they were going to start taxying with a bicycle in the cabin until I advised them that if they did I would be contacting IATA.

 

 

[Guest pelorus32]

The accident report is a fascinating read.

 

The whole approach was unstabilised with speeds up to 293 knots whilst under 10,000 feet and sink rates of up to 3,500fpm. At 1568 AMSL or 953 AGL the aircraft was doing 245 knots and the descent rate was 2,880 FPM!!! The GPWS was screaming its head off and at some similar point the co-pilot (PNF) said "Wah, capt go around capt". the Captain didn't even respond.

 

Vref was 134 knots for flaps 40 and they touched down at 221 knots at flaps 5. At times they were nearly 1800 feet above the glideslope. the glideslope itslef was an unusually steep 5.42 degrees.

 

the PIC had around 13000 hrs and the P2 had around 1550 hours of which about 1360 was on type. The power gradient in the cockpit was almost insurmountable.

 

This was a complete and utter stuff up. But we shouldn't be calling for prosecution of the crew. The cause was, as usual, a bucketload of system failures all lining up with a couple of clowns to create a tragedy. The report shows up issues in check and training at Garuda, oversight failures by the regulator, failures by the airport and crash and fire...a complete shambles end-to-end.

 

Worth a read. Download from this page but it's a large file.

 

http://www.dephub.go.id/knkt/ntsc_aviation/aaic.htm

 

Regards

 

Mike

 

 

[Ben Longden]

The pilot ignored 15 warnings and requests for a go-around, so I read (Melb Age).

 

Scary.

 

Ben

 

 

[Guest J430]

pelorus32

 

I agree that often accidents are pinned on the crew when in fact its only a small part in the problem that they played.

 

In this case there has been a myriad of systemic problems, way way too many in fact. many people should be prosecuted I think. And in this case the Captain should be. The F/O well I feel for him, he has called the GA and with the cultural thing I can see why he did not force it. All that being said, with raw data like that If I was a PAX on that flight and could get to the throttle they would have been slammed forward! The F/O should have also done the right thing.

 

It was a stuff up of the highest order and in this case the crew are not to be treated softly.....nor a lot of others who contributed.

 

J

 

 

[Guest pelorus32]

Besides feeling that as a pax I have a right to expect way more than this; and feeling that the poor people who were killed and injured should never have been subjected to this sort of thing; the person I feel most for is the poor b@@@stard of a P2. He is certainly going to get crucified on the basis that he was supposed to be the final piece in the defences and he didn't take over.

 

I discussed this with an experienced heavy driver I know. His concern was that if the P1 was doing the things he was doing he wasn't going to let some little pisqueek take over from him so then you end up with a wrestle for the yoke.

 

Then even if the P2 did manage to get control and avert disaster the P1 would have seen to it that his life was at best a misery and at worst that he was unemployed.

 

The P2 was just like those poor pax - he couldn't win.

 

My problem with prosecution is that you just end up with layer upon layer of cover ups and all of a sudden nobody will talk to ATSB/NTSB/NTSC et al because they are no longer the safety investigator, they're the criminal investigator.

 

Safety at the moment relies on disclosure of incidents. Prosecute and you lose that.

 

Having said this one part of me feels that this was so bad and so blatant that you have little other choice than to ensure that the P1 never flies again.

 

Regards

 

Mike

 

 

[facthunter]

Reasons?

 

It's got to go back to training/ checking standards. I heard that there is a fuel performance bonus. Does this produce a situation which tends to be anti- go round? The questions asked by the operator after a go-round is performed, tend to apply pressure to the PIC., & result in a press-on mentality, rather than face the paperwork involved. The Pilot was given a visual approach. Performing these is not common practice in many parts of the world these days in airline ops.& the pilot did not perform a visual approach,( this in itself did not cause the accident, but may have made awareness of the situation more a question of bad numbers, than reality) but the pilot continued on, putting the aircraft into a situation which became increasingly impossible to configure the aircraft and land from.

 

There is no doubt that the pilot is overloaded at this point, and has completely lost the ability to assess his situation and manage the flight. A rational & trained person would have aborted the approach when it was obvious that a stabilised approach could not be achieved. It is significant that no Indonesian airline is allowed into european airspace due to poor standards at the moment. Nev...

 

 

[Yenn]

Why go soft on the co pilot. What was his job supposed to be? I am sure any one of us in the cockpit would have tried to take over if we had been proficient, even if only to preserve our own life.

 

We do not need pilots on air liners who are incompetent. But as I have said before we should look at the airline and decided if we want to fly with them. In the same way as we would look at our fellow RAAus pilots.

 

 

[Ben Longden]

Speaking with a bloke at work, whose son is a 747 driver, it would appear a cultural problem exists within the airlines of Indonesia... where it is seen as a professional and personal 'loss of face' to challenge the Captain and even more so for the Captain to entertain the thought of, let alone carry out a Go Around.

 

Ben

 

 

[facthunter]

Cultural factor.

 

Probably very significant, this. The senior pilots are often from ex-airforce sources with fairly high rank and little multi-crew time. Loss of face is a serious matter in many of these countries, and accounts for the reluctance and ineffectiveness of the co-pilot's input.

 

Australia's good safety record has been attributed, in part, to the fairly uninhibited input from other crew. Better resource management. Nev..

 

 

[Ben Longden]

Amen to that.

 

The bloke at work was telling me of a flight his son went on and was right seat to a new Captain, when he was introducing himself, he said "now, you're not going to let me make any stupid mistakes, are you?"

 

Ben