Real Men don't go around - a fatal cultural flaw.
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A GARUDA Boeing 737 was travelling at 410kmh, nearly double normal landing speed, when it slammed into Yogyakarta Airport's runway last month, bouncing, bursting into flames and killing 21 people, the crash investigators' report says.
The confidential report, which Indonesian authorities are trying to suppress, points towards pilot error as the cause of the crash. Aviation experts confirmed speed and flap warnings would have been sounding in the cockpit and the pilot should have aborted the landing and "gone around".
Whether there is a cultural problem with Asian airlines or not if this report is accurate there seems to be a problem with Garuda which is endemic.
The confidential report, which Indonesian authorities are trying to suppress, points towards pilot error as the cause of the crash. Aviation experts confirmed speed and flap warnings would have been sounding in the cockpit and the pilot should have aborted the landing and "gone around".
Whether there is a cultural problem with Asian airlines or not if this report is accurate there seems to be a problem with Garuda which is endemic.
Actually I don't think you can say that 410 km/h is almost twice as fast as usual however...
410 km/h = 220 kt
At Max Landing Weight (56 tons) FLAP 40 Vref = 138 kt
Approach speed would be 143 kt. Assuming the temperature was 30C the TAS would be 148 kt.
220/148 = 1.486. (You could hardly say that was almost twice as fast as usual.)
However 1.486^2 = 2.21 (You CAN say it had OVER TWICE the kinetic energy that it should have had.
Put another way, it had the combined energy of two B737's. One approaching at the correct speed of 148 kt TAS (143 kt IAS), and the other approaching at 162 kt TAS (157 kt IAS).
Or put even another way, it had the same enery as three B737's. Two at the correct speed of 148 kt TAS and the third at 66 kt TAS.
(148 kt = 272 km/h)
(66 kt = 122 km/h)
Don't underestimate the power of velocity squared!
410 km/h = 220 kt
At Max Landing Weight (56 tons) FLAP 40 Vref = 138 kt
Approach speed would be 143 kt. Assuming the temperature was 30C the TAS would be 148 kt.
220/148 = 1.486. (You could hardly say that was almost twice as fast as usual.)
However 1.486^2 = 2.21 (You CAN say it had OVER TWICE the kinetic energy that it should have had.
Put another way, it had the combined energy of two B737's. One approaching at the correct speed of 148 kt TAS (143 kt IAS), and the other approaching at 162 kt TAS (157 kt IAS).
Or put even another way, it had the same enery as three B737's. Two at the correct speed of 148 kt TAS and the third at 66 kt TAS.
(148 kt = 272 km/h)
(66 kt = 122 km/h)
Don't underestimate the power of velocity squared!
Last edited by Blip; 7th Apr 2007 at 00:48.
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I don't think loss of face is the main reason, it is certainly a factor post event but poor training is more the reason I think. They are simply not trained that a go-around is always a possibility and always a reasonable result from any approach should the circumstance call for it. Poor training is the biggest factor in most accidents.
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Whether the problem is cultural or poor training or even basic ability I can think of 2 questions immediately.
1:What was the captain thinking?
2:Why didn't the F/O question the captain during the approach?
1:What was the captain thinking?
2:Why didn't the F/O question the captain during the approach?
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Been an interesting thread however the real reason (and starting point for any fix) for the problems has been missed.
There will be no effective CRM in Asia until airline management make it a clear cut company requirement and outline the requirements and obligations of both the F/O and the Captain.
Someone can confirm exact layout but I believe (for example) Qantas, in their Ops Man, have the CRM pyramid explained, how the F/O gradually increases his forcefulness until a point where he makes a final demand (I believe it is something like "Captain you must listen to me") before taking control of the aircraft IF the Captain has not responded to any of the F/O's increasing concerns.
The requirements for both pilots and steps taken are laid out in black and white and the support of the company is mandatory as it is in their legal operating documents.
I would be surprised if any asian-management airline has more than something like "CRM is good and should be used by pilots to assist safety" in their Ops Man's (but more than happy to be corrected.)
Without the requirements from the company being clearly and unequivocably laid out for both crew members and the company demonstrating their support as above all the training in the world will be (almost) useless, bottom line will be the cultural norms/expectations of "face" and "age" and "position."
There will be no effective CRM in Asia until airline management make it a clear cut company requirement and outline the requirements and obligations of both the F/O and the Captain.
Someone can confirm exact layout but I believe (for example) Qantas, in their Ops Man, have the CRM pyramid explained, how the F/O gradually increases his forcefulness until a point where he makes a final demand (I believe it is something like "Captain you must listen to me") before taking control of the aircraft IF the Captain has not responded to any of the F/O's increasing concerns.
The requirements for both pilots and steps taken are laid out in black and white and the support of the company is mandatory as it is in their legal operating documents.
I would be surprised if any asian-management airline has more than something like "CRM is good and should be used by pilots to assist safety" in their Ops Man's (but more than happy to be corrected.)
Without the requirements from the company being clearly and unequivocably laid out for both crew members and the company demonstrating their support as above all the training in the world will be (almost) useless, bottom line will be the cultural norms/expectations of "face" and "age" and "position."
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(I believe it is something like "Captain you must listen to me")
So, galdian .... look surprise!
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220kts now thats faster over the fence than the french lady ( Mirage III ), what about the tyre speed on a B737?, max for a bus is 195kts.
All you B737 pilots out crunch the numbers from your QRH, what landing distance is required verses landing dist available.
For an A320 220 kts is still 27kts faster than required over the threshold at MTOW (Vref +50) for a flaps & slats at zero app, the LDR is about 2640m if done correctly, how long was the r/w?
All you B737 pilots out crunch the numbers from your QRH, what landing distance is required verses landing dist available.
For an A320 220 kts is still 27kts faster than required over the threshold at MTOW (Vref +50) for a flaps & slats at zero app, the LDR is about 2640m if done correctly, how long was the r/w?
Nunc est bibendum
2:Why didn't the F/O question the captain during the approach?
Also, a flap warning I can understand- although realistically I thought 'too low, flap' would be a GPWS warning rather than a flap warning- but I must be having a slow night tonight because I can't think of a single speed warning that they'd get?!?!
Perhaps it's my lack of 737 experience! 
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RW length at Yokyakarta
OK 3 wire writes
Jepps dated 12JAN07 page 11-1 for WARJ/JOG YOGYAKARTA, INDONESIA ADI SUTJIPTO, states the rwy length at 7218 feet or 2200 metres with a 82ft/25m stopway at the western end and a 197ft/60m stopway at the eastern end.
For an A320 220 kts is still 27kts faster than required over the threshold at MTOW (Vref +50) for a flaps & slats at zero app, the LDR is about 2640m if done correctly, how long was the r/w?
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1:What was the captain thinking?
2:Why didn't the F/O question the captain during the approach?
I would be surprised if any asian-management airline has more than something like "CRM is good and should be used by pilots to assist safety" in their Ops Man's (but more than happy to be corrected.)
Now after seeing the preliminary report, and other data from this accident presented in front of me, the case of GA200 was preventable, the F/O called the go around, but him not having a stunning record himself, was afraid that the captain would pull the rabbit out of the hat on the last moment so didn't take over even when it was obvious that the aircraft had violated GA's SOPs. To partly understand the partial incapacitation, one must look at the data from the initial descent phases. Out of ordinary wind above 10,000ft on the descent started the stress increases early on. The aircraft hit the right VNAV profile albeit a little fast at 9000, and then at 4000ft@8DME to JOG VOR, the "wild" speeds started after that, in that they were not configured quickly enough but decided to chase the visual slope instead. From 3500 - 1500ft, the altitude/speed trade off resulted in the aircraft peaking at 280 knots IAS during this stage, but from then the speed bled off gradually and the aircraft was on slope on the last 200ft... but with the speed, it was at 3000fpm ROD.
Talking to some sources within GA and the investigators reveal that it is their opinion that the Captain suffered from partial incapacitation and the F/O did not take the required measures until it was too late. The GA accident has little to do with the problem of "real men don't go around."
PK-KAR
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PK-KAR,
What do you or GA mean when you say that the captain had a partial incapacitation?
The Indonesian authorities are now saying that there was no argument on the flight deck.Where did you get the information that the F/O questioned the captain?
There seems to be some conflicting info from the authorities .
What do you or GA mean when you say that the captain had a partial incapacitation?
The Indonesian authorities are now saying that there was no argument on the flight deck.Where did you get the information that the F/O questioned the captain?
There seems to be some conflicting info from the authorities .
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Stabilised Approach Criteria?
Are not these guys bound by any stabilised approach criteria? Clearly a 3000 fpm rate of descent at 200 feet screams "here comes the crash". Can anyone enlighten us on whether Garuda must be established within stabilised approach criteria by 500 feet?
Also how about the air traffic controllers? Surely they would have observed the erratic descent profile? Was anything said? Or perhaps erratic descent profiles are the norm??? Just wondering..................................
Also how about the air traffic controllers? Surely they would have observed the erratic descent profile? Was anything said? Or perhaps erratic descent profiles are the norm??? Just wondering..................................
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What do you or GA mean when you say that the captain had a partial incapacitation?
Can anyone enlighten us on whether Garuda must be established within stabilised approach criteria by 500 feet?
In the case of GA200, assuming the report of high rate of descent close to the runway is accurate, as well as a 'too low flap' GPWS alert this would have been followed by a 'sink-rate sink-rate' and possibly even a 'whoop whoop pull-up' GPWS. You would think that self preservation on the part of the FO would have kicked in at this point?
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EY777 could I just ask - your previous airline, a "major operator based in South East Asia", was that an airline run by Asian management or with a significant Western input (thinking of Cathay and Singapore type airlines) ??
So far you are the only response regarding a detailed breakdown of CRM in the Ops Man (early days yet, true) and that could be negated if your major airline does have significany Western input.
I still reckon if I were to bet the VAST majority of ASIAN managed airlines will have nothing more than a bland statement regarding CRM I'd be on a winning bet
No amount of training will offset the lack of management leadership and direction on this issue.
PK-KAR: have always enjoyed your information and input but in all fairness there is a huge difference between being "out of the slot" and being "unrecoverable."
On slope and V/S but 10 kt fast @ 200' is out of the slot, on slope but V/s 3000fpm and speed?? @ 200' is unrecoverable as indeed it was @ 1500' if the speed was anywhere near 280kt.
Shoot the messenger if you want but it is sounding like the "fix" is in: conflicting stories and data are being released, now the investigators are leaking conjecture suggesting the Captain had partial incapacitation (based on what hard, if any, evidence?? at least if he had full incapacitation you might think about it but how are you going to "prove" partial??) and the F/O (whom now is less than average and himself " did not have a stunning record ") failed to do his duties.
Captain not to blame (sympathy for his sad sad plight) and the F/O is fully to blame, CRM not in question as the Captain was out of it!
aerostatic - regarding your final sentence IF the company manual does not clearly lay out the required CRM procedures for both crew members thereby obligating company support this accident would indeed indicate that potential death is preferable to going against the bottom line of cultural norms and expectations.
So far you are the only response regarding a detailed breakdown of CRM in the Ops Man (early days yet, true) and that could be negated if your major airline does have significany Western input.
I still reckon if I were to bet the VAST majority of ASIAN managed airlines will have nothing more than a bland statement regarding CRM I'd be on a winning bet
No amount of training will offset the lack of management leadership and direction on this issue.
PK-KAR: have always enjoyed your information and input but in all fairness there is a huge difference between being "out of the slot" and being "unrecoverable."
On slope and V/S but 10 kt fast @ 200' is out of the slot, on slope but V/s 3000fpm and speed?? @ 200' is unrecoverable as indeed it was @ 1500' if the speed was anywhere near 280kt.
Shoot the messenger if you want but it is sounding like the "fix" is in: conflicting stories and data are being released, now the investigators are leaking conjecture suggesting the Captain had partial incapacitation (based on what hard, if any, evidence?? at least if he had full incapacitation you might think about it but how are you going to "prove" partial??) and the F/O (whom now is less than average and himself " did not have a stunning record ") failed to do his duties.
Captain not to blame (sympathy for his sad sad plight) and the F/O is fully to blame, CRM not in question as the Captain was out of it!
aerostatic - regarding your final sentence IF the company manual does not clearly lay out the required CRM procedures for both crew members thereby obligating company support this accident would indeed indicate that potential death is preferable to going against the bottom line of cultural norms and expectations.
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Lowerlobe,
Based on information I've received to date, there were no arguments in the flight deck. The F/O questioning the Captain does not mean an argument took place.
Lokione,
They were. It's stable 500ft for visual with Garuda. From seeing the data on the flight path, it appeared that they managed to get on the slope at 500' but were way out on the speed.
Galdian,
Out of the slot or unrecoverable in this case doesn't mean much, it just means they should have done something (and with all our benefit of having hindsight of course).
Excuse my bad previous post, I've just had a look at the notes I took immediately after seeing the report yesterday... it was 250kts at 4000 & 3500, 284kts @ 3000, 272@2500, 254@2000, 232@1500, 220@1000 all the way down. (not that it doesn't change the required action much).
After hitting JOG 8DME @ 4000 at 250kts, they tried to chase DME3.5@2500 with flaps 1. I'm still waiting for info on A/P and A/T status on this segment. They overshot the equivalent of the ILS Final Approach Fix (3.5@2500) by a few hundred feet only, but ended up chasing the (visual) slope and it was flaps 5@2000. The rate of descent until they hit that glideslope was 3000fpm... they somehow followed the last few hundred feet on the slope and then the "flare" prolonged the time airborne... Even by then, the ability to stop was "academic"...
The initial report doesn't give any info on the overall descent from FL270. Sources inside the investigation and Garuda has leaked out comments from the CVR such as wind, and it has been said that the F/O did question and/or call for go-around at 3 occassions... the last being around 500' or 200' AGL.
As to partial incap, the evidence, if any, has yet to be made public. I have been told that the CVR will be checked again, to see of signs of stress and other possibilities in the Captain's voice and also of the F/O's. The "shrinks" have been called in aswell.
Whether this is fixed or not, only time will tell, but the information on partial incap and the calls for the G/A as well as the speeds and descent path were leaked weeks back. I am told the minister has tried to suppress it but the NTSC wants it opened. There's a battle going in the NTSC between those capitulating to the minister's threats, and the NTSC's senior members. It was after a reported "pressure from outside the DoT" that the minister yielded.... but that's not the end of the story yet.
PK-KAR
Based on information I've received to date, there were no arguments in the flight deck. The F/O questioning the Captain does not mean an argument took place.
Lokione,
They were. It's stable 500ft for visual with Garuda. From seeing the data on the flight path, it appeared that they managed to get on the slope at 500' but were way out on the speed.
Galdian,
Out of the slot or unrecoverable in this case doesn't mean much, it just means they should have done something (and with all our benefit of having hindsight of course).
Excuse my bad previous post, I've just had a look at the notes I took immediately after seeing the report yesterday... it was 250kts at 4000 & 3500, 284kts @ 3000, 272@2500, 254@2000, 232@1500, 220@1000 all the way down. (not that it doesn't change the required action much).
After hitting JOG 8DME @ 4000 at 250kts, they tried to chase DME3.5@2500 with flaps 1. I'm still waiting for info on A/P and A/T status on this segment. They overshot the equivalent of the ILS Final Approach Fix (3.5@2500) by a few hundred feet only, but ended up chasing the (visual) slope and it was flaps 5@2000. The rate of descent until they hit that glideslope was 3000fpm... they somehow followed the last few hundred feet on the slope and then the "flare" prolonged the time airborne... Even by then, the ability to stop was "academic"...
The initial report doesn't give any info on the overall descent from FL270. Sources inside the investigation and Garuda has leaked out comments from the CVR such as wind, and it has been said that the F/O did question and/or call for go-around at 3 occassions... the last being around 500' or 200' AGL.
As to partial incap, the evidence, if any, has yet to be made public. I have been told that the CVR will be checked again, to see of signs of stress and other possibilities in the Captain's voice and also of the F/O's. The "shrinks" have been called in aswell.
Whether this is fixed or not, only time will tell, but the information on partial incap and the calls for the G/A as well as the speeds and descent path were leaked weeks back. I am told the minister has tried to suppress it but the NTSC wants it opened. There's a battle going in the NTSC between those capitulating to the minister's threats, and the NTSC's senior members. It was after a reported "pressure from outside the DoT" that the minister yielded.... but that's not the end of the story yet.
PK-KAR
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galdian, it was Malaysia Airlines.
There are no major or significant Western Input, but like SQ (which are majority wise, asian management) they are safety conscious & have a very pro active flight safety department.Their pilots are represented by associations (not a union) & are actively involved with IFALPA on safety matters.
As much as the airline wasn't making money (a different issue ), safety has always been their number one policy.I believe SQ shares the same ethos as both airlines are commited to their masters....the government of each nation.An accident will be the biggest 'face losing' an asian nation can experience! 
PK-KAR, it looks more & more like mental fixation (in a way, also considered a subtle incapacitation).Interestingly, the F/O looks like he might have been going along with the approach until he realised the gravity of the situation & tried to salvage the situation but either he was too late or not forceful enough (to snap the skipper out of his mental state).
There are no major or significant Western Input, but like SQ (which are majority wise, asian management) they are safety conscious & have a very pro active flight safety department.Their pilots are represented by associations (not a union) & are actively involved with IFALPA on safety matters.
As much as the airline wasn't making money (a different issue
), safety has always been their number one policy.I believe SQ shares the same ethos as both airlines are commited to their masters....the government of each nation.An accident will be the biggest 'face losing' an asian nation can experience! PK-KAR, it looks more & more like mental fixation (in a way, also considered a subtle incapacitation).Interestingly, the F/O looks like he might have been going along with the approach until he realised the gravity of the situation & tried to salvage the situation but either he was too late or not forceful enough (to snap the skipper out of his mental state).
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EY777: thanks for that, I hadn't thought of Malaysian in the context of Cathay or Singapore but it makes sense when you consider they evolved from MSA of the 70's (???), I assume the culture was set then and has simply evolved in both companies as factors such as CRM have grown in significance.
Could I ask - do EY have the "CRM pyramid" (or similar) or something else?? Just interested.
Still think I'd win the bet though - maybe the qualification should have been "western management or significant western operatives therefore subtle input", thinking about China they have only seen western crews in the last 5 years and western crews have never been a part of mainline airlines in Japan (subsiduries/offshoots yes.)
No political discussions about Taiwan please anyone.
PK-KAR: with the various uncertain, contradictory "facts" floating around I am sure more than ever the "fix" is in place.
Question: do not know your position but do you know if Garuda Ops Mans have a "CRM pyramid" or similar (as discussed earlier) outlined in detail??
What DO they have??
Intesesting discussion, thanks all!
Could I ask - do EY have the "CRM pyramid" (or similar) or something else?? Just interested.
Still think I'd win the bet though - maybe the qualification should have been "western management or significant western operatives therefore subtle input", thinking about China they have only seen western crews in the last 5 years and western crews have never been a part of mainline airlines in Japan (subsiduries/offshoots yes.)
No political discussions about Taiwan please anyone.
PK-KAR: with the various uncertain, contradictory "facts" floating around I am sure more than ever the "fix" is in place.
Question: do not know your position but do you know if Garuda Ops Mans have a "CRM pyramid" or similar (as discussed earlier) outlined in detail??
What DO they have??
Intesesting discussion, thanks all!
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Galdian,
I wonder what the various uncertain and contradictory facts are? The preliminary report does not suggest a cover up. The police is ready to continue its criminal investigation, to which the NTSC report cannot be used as evidence... knowing the police here, they'd probably want to slam the pilots into jail regardless.
All the talk about fixation or partial incap came as a result of the data presented, and is subject to examination by the human factors section of the GA200 investigation in the NTSC.
What makes me wonder is what are the conflicting stories? The case on argument or no argument is to me more or less solved... go around calls were made by the F/O. There have been cases in Garuda where the F/O had to take control and report the captain for "violations of SOPs due to/or with fixation".
As to the content on the CRM section of the company's manual, I do not know. I don't work for Garuda. All I know are cases of CRM failures and CRM successes...
Centaurus,
Call it whatever you want... call it a freak day, call it "the Captain capitulated to the real men don't go around culture after 20 years flying", or whatever else. Not going around in such a situation does not conform with what's been heard of captain Marwoto's normal behaviour.
PK-KAR
I wonder what the various uncertain and contradictory facts are? The preliminary report does not suggest a cover up. The police is ready to continue its criminal investigation, to which the NTSC report cannot be used as evidence... knowing the police here, they'd probably want to slam the pilots into jail regardless.
All the talk about fixation or partial incap came as a result of the data presented, and is subject to examination by the human factors section of the GA200 investigation in the NTSC.
What makes me wonder is what are the conflicting stories? The case on argument or no argument is to me more or less solved... go around calls were made by the F/O. There have been cases in Garuda where the F/O had to take control and report the captain for "violations of SOPs due to/or with fixation".
As to the content on the CRM section of the company's manual, I do not know. I don't work for Garuda. All I know are cases of CRM failures and CRM successes...
Centaurus,
Call it whatever you want... call it a freak day, call it "the Captain capitulated to the real men don't go around culture after 20 years flying", or whatever else. Not going around in such a situation does not conform with what's been heard of captain Marwoto's normal behaviour.
PK-KAR
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Just a thought .... if calling for a go around by an F/O (thereby over ruling the Captain's decision) is an issue for cultural reasons or other, then could this be alleviated by technology? ie, have the aircraft's systems call for a go around when an unstablized approach and landing is detected, ie, smiliar to the ground proximity warnings/TCAS alerts? I'd imagine a Captain in such circumstances would be more inclined to comply with a computer than his F/O, and the non-assertive F/O would not have to worry about the consequences either. Just my two rupiah's worth.