Names removed. Though I am sure they are in the report
Indonesian police may try to force air safety investigators to provide evidence against a pilot who
ignored fifteen alarms and requests to abort a landing before crashing into Yogyakarta's airport
runway, killing 21 people. The National Transportation Safety Committee investigation into the
March crash has revealed numerous safety breaches by the Garuda pilot, along with serious
deficiencies in training and airport safety procedures. However, committee chairman, Tatang
Kurniadi, said evidence gathered would not be provided to police, provoking anger from relatives of
victims, who included five Australians.
Committee staff would refuse to be interviewed by police, Mr Kurniadi said. He also refused to
release the Boeing 737's "black box" recordings, stating this would breach international aviation
protocol. The chief detective overseeing the investigation said information from the box was key to
the police case. Mr Kurniadi said his staff would refuse any police summonses, and would only testify
in court if charges were laid.
The report stated that pilot descended too steeply at an excessive speed. "During
the approach, the Ground Proximity Warning System alerts (GPWS) and warnings sounded fifteen
times and the co-pilot called for the pilot to go around." The warnings included audible alarms stating
"Too low, terrain" and "Whoop, whoop, pull up". The pilot continued to descend at nearly twice the
maximum safe speed. When it touched the runway the plane bounced and the co-pilot again
screamed to "go around" and abort the landing. The report found rescue and fire vehicles were
unable to reach the crash site and some did not have appropriate fire suppressant.
Mr Kurniadi said the report did not include the terms "human error" or "pilot error" as that would
suggest the pilot was "100% to blame". He said other factors were involved. The aircraft was in good
condition and there was absolutely "no technical fault". The investigation had no authority to
apportion blame, said Indonesia's Transport Minister, Yusmou Syafei Djamal. "The purpose is to
prevent another crash." He said all recommendations would be implemented but could not say when
the runway would be extended to meet international safety standards.
The report found that there had been only one review of Garuda's safety records by airline regulators
in the past nine years. It was critical of Indonesia's Civil Aviation Directorate for failing to ensure
Garuda's safety standards were adequate. Indonesia's police say they are considering their own
investigation which will not have access to the committee's evidence. The co-pilot was also criticised
for not taking control of the aircraft when it was clear the landing conditions were unsafe.
The pilot reportedly did not respond to or disregarded the “very loud” GPWS alerts and warning
phrases that were issued to the cabin in English, but officials have ruled out a language barrier. The
pilot was heard on the cockpit voice recorder saying “wah, nggak beres nih'' (something's not right).
The report accused the pilot of being "fixated or channelised" on landing the plane and the co-pilot of
failing to follow procedures and take over the controls when the pilot ignored warnings. Captain
Pilot and co-pilot, are still grounded. Late yesterday both the
Garuda Pilot's Association and Garuda refused to comment.
The report noted that Captain was singing and engaging in non-essential conversation during
the crucial descent from 10,000 feet to 4000 feet, and that during flight simulator and pilot line testing
last year and in 2005, the 45-year-old had made landing approaches that were too fast. The report
makes recommendations that Garuda clarify its policy on fuel conservation, which has been identified
as a possible reason why pilots choose not to make “go-around'' landings, which burn extra fuel.
The disaster was set in motion sixteen kilometres from the landing zone, when Captain
realised he was significantly higher than he should have been. He reduced altitude sharply, causing the
plane to speed up significantly. However, co-pilot ignored his captain's direction to extend
the landing flaps to their full approach setting. Rather than putting them to 40 degrees, the co-pilot set
the flaps to only five degrees, which, the report notes “is not a landing flap setting'', and called for a
go-around.
With its wing flaps improperly set for landing, the plane hit the runway at 409km/h, 161km/h faster
than the required speed. Shortly afterwards the aircraft's nose wheel structure collapsed and the
plane crashed into an embankment and a paddy field, where fuel from its ruptured tanks quickly
caught fire, destroying the fuselage completely. "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 said.