Yogyakarta’s painful transparency

That the report is so damning of the pilot just makes the actions of the Indonesian authorities all the more praiseworthy for it was only a short time ago that accidents in that country were covered up and official reports rarely surfaced.

While the contents are sickening the quality and detail of the report is to be praised.

Paraphrased, the report states that: The pilot in command (PIC) – a veteran of 22 years with Garuda – was flying the 737 and intended to make an instrument landing system (ILS) approach to runway 09 at Yogyakarta and briefed the copilot accordingly.

Yogya Approach 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, but did not inform the controller and the descent and approach were conducted in visual meteorological conditions.

At 23:55:33 (UTC – 0655 local), when the aircraft was 10. 1 miles from the runway, it was 1427ft above the initial fix of 2500ft published in the approach chart, and the airspeed was 283kt. The PIC descended the aircraft steeply in an attempt to reach the runway, but in doing so, the airspeed increased excessively.

As the aircraft was being flown at speeds that were in excess of the wing flaps operation speed, the copilot elected not to extend the flaps as instructed by the PIC. During the approach, the ground proximity warning system (GPWS) alerts and warnings sounded 15 times, and the copilot called for the PIC to go-around.

The PIC continued the approach with flaps five degrees, and the aircraft attained the glideslope near the runway 09 threshold. The aircraft crossed the threshold, 89ft above the runway, at an airspeed of 232kt, 98kt faster than the required landing speed for a flaps 40 degrees.

The wind was northeasterly at 9kt and the groundspeed was 235kt.

The aircraft touched down at an airspeed of 221kt, 87kt faster than landing speed for 40 degrees flap.

Shortly after touching down, the copilot called, with high intonation, for the PIC to go around. The aircraft overran the departure end of runway 09, to the right of the centerline at 110kt.

The aircraft crossed a road, and impacted an embankment before stopping in a rice paddy 252 metres from the threshold of runway 27 (departure end of runway 09). The aircraft was burnt by the impact forces and an intense, fuel fed, post impact fire. There were 119 survivors. One flight attendant and 20 passengers were fatally injured. One flight attendant and 11 passengers were seriously injured.

H H H Neither of the flightcrew followed company procedures, but far worse, Garuda simulator records showed no evidence of training or proficiency checks in the actions and responses to be taken in the event of GPWS or EGPWS alerts and warnings.

There was also no evidence of any simulator pilot-proficiency check for the copilot to take control of the aircraft from the PIC, and execute a go around, when an unsafe condition exists.

Even worse, the report found that the Directorate General of Civil Aviation’s (DGCA) flying operations surveillance of Garuda was not effective in identifying these and other safety deficiencies and had only done one audit in seven years – four years ago – and had never made the results known to the airline.

The NTSC has made 19 safety recommendations and five safety actions to Garuda, Indonesian airlines, the airport, and the DGCA.

But it remains to be seen if these bodies will take Indonesian air safety as seriously as the NTSC. In the meantime it is clear that travel on airlines that do not carry out basic simulator proficiency training for emergencies is dangerous. o