Description

On 7 March 2007, a Boeing 737-400 being operated by Garuda landed on a scheduled passenger flight from Jakarta Soekarno-Hatta to Yogyakarta overran the end of the destination runway at speed in normal daylight visibility after a late and high speed landing attempt ending up 252 m beyond the end of the runway surface in a rice paddy field. There was a severe and prolonged fire which destroyed the aircraft (see the illustration below taken from the Investigation Report) and 21 of the 140 occupants were killed, 12 seriously injured, 100 suffered minor injuries and 7 were uninjured.

Investigation

An Investigation into the Accident was carried out by the Indonesian National Transportation Safety Committee (NTSC). It was established the approach, with the aircraft commander as PF had been unstable and conducted at excessive speed and a high rate of descent with a number of Terrain Avoidance and Warning System (TAWS) warnings generated.

The Investigation established that the aircraft commander had been PF and had intended to make an ILS approach to Runway 09 at Yogyakarta and had briefed the co pilot accordingly. However, ATC at Yogyakarta 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 ATC. It was found that at 10.1 miles from the runway, the aircraft was 1427 ft higher than the published ILS IAF of 2500 ft at 283KIAS. The aircraft was then descended steeply in an attempt to reach the runway but the airspeed increased excessively. Because the aircraft was being flown at speeds that were in excess of the wing flap operation speed, the copilot elected not to extend the flaps as instructed by the PF. During the approach, Warnings and Alerts from the GPWS/TAWS were activated on 15 occasions. The co pilot called for a go around but the PF continued the approach with flaps at 5 degrees and the aircraft reached the ILS GS near the landing runway threshold. It was noted that 5 degrees is not a landing flap setting. The aircraft crossed the threshold, 89 feet above the runway, at 232 knots airspeed, 98 knots faster than the required landing speed for flaps 40 degrees. and touched down at 221 knots, 87 knots faster than landing speed for 40 degrees flap. Shortly after touching down, the copilot called, with high intonation, for the PF to go around but this was ignored. The actual approach profile compared to the ILS procedure is shown below in a diagram taken from the official Report.

• The aircraft was flown at an excessively high airspeed and steep descent during the approach and landing, resulting in an unstabilised approach.
• The aircraft commander 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.
• The co pilot did not follow Company instructions and take control of the aircraft from the aircraft commander when he saw that he was repeatedly ignoring warnings to go around.
• The aircraft commander’s attention became channeled and fixated on landing the aircraft.
• The aircraft commander did not respond to 15 Ground Proximity Warning System (GPWS) alerts and warnings and two calls from the copilot to go around.
• The Indonesian DGCA lacked a mechanism for ensuring the continued safety standard of flight operations at Garuda.
• The Indonesian DGCA had not filed a difference with ICAO with respect to its inability to comply with the Standard for the runway end safety area.
• The Airport Emergency Plan (AEP) was inadequate to cover an accident emergency occurring outside the airport perimeter.
• It took more than 2 hours to extinguish the fire. The delay in extinguishing the fire, and the lack of appropriate fire suppressant agents, may have significantly reduced survivability.

The Conclusion of the Investigation as to Causes taken from the Report of the Investigation as published were as follows:

1. Flight crew communication and coordination was less than effective after the aircraft passed 2,336 feet on descent after flap 1 was selected. Therefore the safety of the flight was compromised.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The crew did not abort the approach when stabilised approach criteria were not met.
3. The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the co pilot to go around.
4. The co pilot did not follow company instructions and take control of the aircraft from the pilot in command when he saw that the pilot in command repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training for its Boeing 737 flight crews covering vital actions and required responses to GPWS and EGPWS alerts and warnings such as ‘TOO LOW TERRAIN’ and ‘WHOOP, WHOOP PULL UP’.

Safety Recommendations

As result of this investigation, the NTSC issued 19 Safety Recommendations:

• To Garuda Indonesia, That Garuda Indonesia review its fuel conservation incentive program policy to ensure that flight crews are in no doubt about its intent, and that there is no perception that such a policy could compromise the safe operation of aircraft.
• To Indonesian airline operators, That they ensure that their flight crews are trained and checked in ‘GPWS specific’ simulator training sessions, for the vital actions and required responses to Ground Proximity Warning System (GPWS) and Enhanced Ground Proximity Warning System (EGPWS) warnings.
• To Indonesian airline operators, That they review the procedures used by their maintenance organisations for ensuring that flight recorders meet the relevant manufacturers’ specifications with respect to specific aircraft systems such as Electronic Flight Instrument Systems (Electronic Flight Instrument System) or non-EFIS systems. The annual inspection procedures for flight recorders, including functional checks, should also be reviewed to ensure that all parameters are being recorded in accordance with CASR 121.343 and ICAO Annex 6, Part I. 3. 4., Table D-1. The method of inspection should follow the manufacturer specification.
• To Indonesian airline operators, That they ensure that published procedures take into consideration the runway end safety area (Runway End Safety Area) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.
• To Indonesian airline operators, That they include the Flight Safety Foundation (FSF) Approach-and-Landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness modules in their recurrency training programs and conduct initial ALAR and CFIT training for flight crew members who have not yet completed such training.
• To Indonesian airline operators, That they ensure that published procedures provide for:

  (a) the passenger lists to be sent to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin

  (b) the cargo manifest to be sent to the crisis center, rescue and fire fighting services and the National Transportation Safety Committee, within 1 hour, to enable hazard mitigation at the accident site.

• To the Directorate General Civil Aviation (DGCA), That it ensures that airline operators train and check their crews, in the simulator, for the vital actions and required responses to GPWS and EGPWS warnings.
• To the Directorate General Civil Aviation (DGCA), That it ensures that airline operators have published procedures that take into consideration the runway end safety area (RESA) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.
• To the Directorate General Civil Aviation (DGCA), That it reviews its policy, procedures and implementation of flight operation’s surveillance, to ensure that DGCA achieves and maintains adequate and appropriate regulatory oversight.
• To the Directorate General Civil Aviation (DGCA), That it ensures that airline operators have procedures to provide:

  (a) the passenger lists to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin

  (b) the cargo manifest to the crisis center, rescue and fire fighting services and the National Transportation Safety Committee, within 1 hour, to enable hazard mitigation at the accident site.

• To the Directorate General Civil Aviation (DGCA), That it reviews the procedures used by airline maintenance organisations for ensuring that flight recorders meet the relevant manufacturers’ specifications with respect to specific aircraft systems such as EFIS or non-EFIS systems. The annual inspection procedures for flight recorders, including functional checks, should also be reviewed to ensure that all parameters are being recorded in accordance with CASR 121.343 and ICAO Annex 6, Part I. 3. 4., Table D-1. The method of inspection should follow the manufacturer specification.
• To the Directorate General Civil Aviation (DGCA), That it reviews the Yogyakarta runway complex to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in the International Civil Aviation Organisation (ICAO) Annex 14.Particular attention should be given to:

  (a) ICAO Annex 14 Paragraph 3.5.2 (Standard) that a Runway End Safety Area (RESA) shall extend from the end of a runway strip to a distance of at least 90 meters.

  (b) ICAO Annex 14 Paragraph 3.5.3 (Recommendation) that for a Code number 3 airport a runway end safety area (RESA) should, as far as practicable, extend from the end of a runway strip to a distance of at least 240 meters. If the DGCA is unable to meet the RESA Standard in accordance with ICAO Annex 14, it should file a difference with ICAO as soon as possible.

• To the Directorate General Civil Aviation (DGCA), That it reviews the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they:

  (a) meet the minimum requirements specified in the International Civil Aviation Organisation’s Annex 14; and

  (b) meet the requirements to cover the area up to 5 NM (8 Km) from the airport perimeter, as stated in the Transport Ministry Decree 47 (KM47).

• To the Directorate General Civil Aviation (DGCA), That it ensures that airport operators:

  (a) publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and

  (b) have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and

  (c) review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and

  (d) exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years; and

  (e) review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies; and

  (f) ensure that any identified deficiencies are corrected.

• To the Directorate General Civil Aviation (DGCA), That it ensures that airport operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.
• To the Yogyakarta Airport Operator, That it reviews the Yogyakarta runway complex to ensure that the runway end safety area (RESA) meets the dimension Standards prescribed in the International Civil Aviation Organisation (ICAO) Annex 14. Particular attention should be given to:

  (a) ICAO Annex 14 Paragraph 3.5.2 (Standard), that a runway end safety area (RESA) shall extend from the end of a runway strip to a distance of at least 90 meters.

  (b) ICAO Annex 14 Paragraph 3.5.3 (Recommendation) that for a Code number 3 airport, a runway end safety area (RESA) should, as far as practicable, extend from the end of a runway strip to a distance of at least 240 meters.

• To Airport Operators, That they review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they:

  (a) meet the minimum requirements specified in the International Civil Aviation Organisation’s Annex 14; and

  (b) meet the requirements to cover the area up to 5 NM (8 Km) from airport perimeter, as stated in the Transport Ministry Decree 47 (KM47).

• To Airport Operators, That those operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.
• To Airport Operators, That they:

  (a) publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and

  (b) have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and

  (c) review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and

  (d) exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and

  (e) review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and

  (f) ensure that any identified deficiencies are corrected.

The Final Report of the NTSC Investigation may be seen in full at SKYbrary bookshelf:Aircraft Accident Investigation Report KNKT/07.06/07.02.35

Further Reading

• Runway Excursion
• Runway End Safety Area
• Stabilised Approach
• DGAC (France) Publications on Non-Stabilised Approaches
• Runway Overrun After Unstabilised Approach (OGHFA SE)
• Crew Resource Management (OGHFA BN)
• Normal Checklists and Crew Coordination (OGHFA BN)
• Press-on-itis (OGHFA BN)