Report blames pilot error for Garuda Indonesia Flight 200 disaster

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Monday, October 22, 2007

A final report released today has found pilot error to be the cause of the crash of Garuda Indonesia Flight 200 in Indonesia on March 7, 2007. 21 people were killed when the Boeing 737 airliner, carrying 140 people, overshot the runway at Adisucipto International Airport, near Yogyakarta. It crossed a road and then struck an embankment, bursting into flames, before stopping in a rice field, some 252m from the end of the runway.

The pilot is found to have been singing as he began the final descent, in direct contradiction to the Garuda Basic Operations Manual, which calls for activation of the Sterile Cockpit Rule at 10,000 feet and below.

Illustration of a typical go-around procedure. Note that the actual incident differs because the aircraft had bounced off the runway prior to the call for a go-around.

The pilot was probably emotionally aroused because his conscious awareness moved from the relaxed mode “singing” to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilised approach,” the report continued. However, it does say that he was fully aware that something was wrong during the approach, as he is recorded as having said “Oh, there is something not right.”

The report found that that the aircraft was flown by the pilot in command at a speed far exceeding that at which the wing flaps were able to operate properly. The report continues to criticise the pilot further, saying that a cockpit alert by the Ground Proximity Warning System informing the pilot he was flying too fast sounded no less than 15 times, but the pilot failed to abort the landing. He also ignored the co-pilot telling him to execute a 'go-around procedure' after the aircraft struck the runway at speed and bounced back into the air.

The co-pilot is himself found to be at error by the report, which points out that he should have taken over the controls from the pilot when it became clear the aircraft was being flown in a dangerous manner. However, the report did note that Garuda Indonesia had failed to give him any simulator training replicating a situation whereby the co-pilot would take over control duties from the pilot in charge due to unsafe handling of the plane; in fact, training was found to be inadequate for both members of the cockpit crew.

In the report's own words: "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 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."

Authorities were also found to be at fault, with the Indonesian Director General of Civil Aviation criticised for failing to identify inadequacies in pilot training procedures. he was also criticised for the fact that the aircraft had managed to go virtually un-inspected, with only two safety checks in a decade.

The report adds that the Aircraft Rescue and Firefighting facilities at the airport were also lacking on the day of the accident, for struggling to access the crash site and for not having the appropriate fire suppressant upon their eventual arrival. The report says these delays likely had an impact on the survivability factors on board the plane in the moments after crashing, when the aircraft was in flames. It ultimately took more than two hours before the fire was put out. Another criticism leveled at the airport was that it failed to comply with international runway safety regulations.

A Garuda 737, comparable to the one involved in the disaster.
Image: Terence Ong.

The report has triggered a call from Caroline Mellish, sister of Australian Financial Review Morgan Mellish, one of five Australians killed in the accident, for greater co-operation between different Indonesian authorities. "I think not working together as different departments in a government shows a lack of any sort of system," She said from Jakarta, to which she had travelled for the release of the final report.

"If they can't work together in different departments, I don't know how they are going to run a country and make any difference investigating this sort of accident and ensuring the recommendations do get carried forward to ensure that no more accident happen."

However, she did have some sympathy to spare for the pilot who was in control of the plane that day when the possibility of his prosecution was raised: "I think having 21 deaths on your conscience is probably enough. I don't think prosecuting the man is going to make any difference."

National Transport Safety Committee chairman Tatang Kurniadi said that no information from the report would be used in any criminal or civil liability investigations. "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.

"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.

"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.


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