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Old 8th Apr 2007, 20:17
  #314 (permalink)  
PK-KAR
 
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From what I've seen from the preliminary report:

The report has only the factual information regarding the crash, no details on FDR readouts and no CVR transcripts. The latter two are not being released due to the need for further translation.

However, the FDR data was sighted... and my recollections of them are:

The aircraft hit the right VNAV profile albeit a little fast at 9000 (at 250kts, GA's standard is 220-240 below 10,000, until the initial and final approach fixes), and then at 4000ft@8DME to JOG VOR, @250kts. The "wild" speeds started after that

wind at 4000 was 270@23 kts.
@3500, wind 270/19, speed 250kts
@3000, wind 300/17 or 15, speed 284kts
@2500, wind 270/13, speed 272kts
@2000, wind 270/9, speed 254kts
@1500, wind 270/7, speed 232kts
@1000, wind 270/5, speed 220kts, all the way down to the runway.

Flap1 selected shortly before @2500-ish, followed by a steep descent (by then they had just past the visual glideslope), then flaps 5 @2000.

The visual slope was at 3.5DME JOG @2500', but the aircraft was roughly 2700' at that position.

Throttle was idle all the time below 4000' and until 500', a small throttle movement was detected by the FDR which was idle by the time the aircraft made runway contact.

Speedbrake lever engaged after 1st ground contact, to full deploy, until the recording ended.

Reversers were selected on the throttle during the roll until about the last 7 seconds of the recording, followed by a small forward throttle movement. Reverser nacelle deployment were detected on both sides of both engines until they were stowed about 7 seconds before the end of the recording. There was a reduction in reverser on the throttle during the landing roll at about the middle of the roll, before going to full reversers again.

FDR data so far released for the report only contains the last 4000' of the flight.
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Discussions on contents of the CVR noted the following:
1. Crew commented on the wind during the descent prior to reaching the low level altitudes.
2. At 1500' F/O commented on aircraft being too high and asked if the captain wanted a go-around.
3. At 500' AGL the F/O recommended a go-around.
4. At 200' AGL the F/O called a go-around but did not take control of the aircraft.
5. Captain's reaction to the F/O comments on go-around were that he would configure lower.
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Personal comments:
1. Consistent with ATC transcripts which I also obtained around 11th March.
2. Flight path and chain of events near and on the ground consistent with witness recollection obtained 2 weeks ago.
3. Consistent with leaks on chain of events and secondary source information on conversations going on in the cockpit.
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Further information on GA training since the last 2 years involve not just the "by the book situations" but with abnormalities based on actual accidents and incidents.

In this particular case - the media, whether Indonesian or not, is not going to force government action where it matters - IN INDONESIA.
I've received information that the NTSC wants the report out, but the minister of transport doesn't. However, there have been pressure on the NTSC and DGAC to put this report out regardless of what the minister says.

Would the rating system have appeared if Australian officials hadn't been onboard, with the resultant increased interest from outside Indonesia?
Actually, yes. The list was completed a few weeks before GA200 crash, and then GA was removed from Category I and placed in Category II by the time the report was released.

It looks like it will be another while before we know WHY no GA happened(as in the motivation for continuing a 'hot' approach in the case of GA200). So an answer to the question of whether it was 'shame' or 'bravado' is going to have to wait for the moment.
But then there are the examples of companies which publicly state their training and practice is GA-positive - but pilots have to submit written reports whenever a GA results - often in the environment of finger-waving. Of course, we all know what should happen if a F/O calls for GA - or indeed only corrections from parameters if above 500ft AGL VMC, but there are many F/O's who have a seriously justifiable reason to doubt their 'career indemnity' if they push the issue.
For sure an informal discussion may occur to decipher what preceded the go around
Will try and save the wait and eek more info out. Currently it's fixation/partial incap and lack of F/O assertiveness. Not going around in such a situation does not conform with the Captain's normal behaviour (as testified in conversations with various sources including those who knew the Captain), and the CRM practice (F/O take over in such a situation is part of the training and has happened... with the F/O judged to have made the right call and the Captain grounded).

In conversations with the 'sources', I had raised the possibility that the last 4000' was a result of the descent. Garuda is unique for Indonesia in that the top and upper middle management has a good corporate culture, but a rotten middle to lower management.

"We are going to conduct a further examination of the ill-fated Garuda plane's wreckage later this week to collect additional data relating to technical matters," KNKT spokesman Joseph Tumenggung told Antara on Tuesday.

He said t to uncover the mystery behind the accident , the KNKT needed additional data that could be obtained only by re-examining the plane's wreckage.

"Besides data from the cockpit voice recorders, other information related to technical matters are also needed to uncover the cause of the accident," Joseph Tumenggung said.
This is inevitable. The preliminary report has uncovered that FDR data is incomplete thanks to the wrong type of FDR being put in (for 737 non-EFIS instead of 737EFIS). This results in data mismatch, and several parameters missing.

From the example given by Centaurus above – what is the point of having someone in the right-hand seat who just blurts out “500 AGL – stabilised”, regardless of what is actually happening? Whether that F/O is well trained or not - he's contributing nothing to the overall safety picture.
There was little evidence of the Western ‘social’ CRM, together with many weaknesses in the basics - airmanship, situation awareness, rules and procedures, and aviation knowledge.
Add comments like the quoted with crashes like GA200 and possibily other incidents that never made it out are examples of the hazards a company have in the middle of changing. The number of "bad pilots" in Garuda is dwindling. Many have moved to other airlines *yikes*, some have been thrown out or retrained until they got the message. Instructors are biting the bad apple and spitting it out into the bin... but the process is not yet complete.

Fire engines and rescue vehicles were unable to reach the crash site quickly and were not properly equipped.
failure of emergency services to respond quickly could have contributed to the crash
The report did mention that the equipment reached the fence within the required amount of time but was unable to proceed further thanks to the embankments on both sides of the road the aircraft went across. The report however criticised the lack of ability for the foam not able to reach further than 140m.

Failure of the emergency services to respond quickly? Didnt the video showing that the ambulances and even a local firetruck arrived within 5 mins (during morning rush hour in JOG roads)??? Can't remember the wording on this.

The report also criticised JOG's lack of compliance to the ICAO Annex 14 (if I remember that correctly), however, only in the section regarding the Runway End Safety Area.

OK... that's a mouthful for tonight.

PK-KAR
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