Indonesian B737 runway overrun/crash
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Question from SLF
In the article in the Australian linked to a few posts back, it said:-
"One minute later, the tower again told flight 200 the wind conditions were calm, and asked the pilots to check the aircraft's landing gear was down and locked before declaring the plane clear to land."
Is that normal? The tower participating in the checklist?
Sorry for thread drift!
M63
In the article in the Australian linked to a few posts back, it said:-
"One minute later, the tower again told flight 200 the wind conditions were calm, and asked the pilots to check the aircraft's landing gear was down and locked before declaring the plane clear to land."
Is that normal? The tower participating in the checklist?
Sorry for thread drift!
M63
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Question from SLF
Let me float a theory/hypothesis call it what you will......
The approach was rushed, to the extent that normal landing flap and Vref(30)+5 was not achieved. The aircraft has #1 reverser locked out (PK-KAR's post #169).
The aircraft touches down with some flap but at very high speed. In order to kill that energy crew apply FULL reverse on the only serviceable reverser and in doing so lose directional control on the runway. The Captain cancels reverse but instead makes a bold NWS input at an inappropriately high G/SPD and the two NW tyres burst. The NW rims shatter on rwy contact and the aircraft overuns the stop-end resting on the main gear an the NW oleo.
Last edited by Magplug; 19th Mar 2007 at 12:58.
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SOPs
If this was a joint civil/military field with military controllers then the normal military SOP is for the controller to say something like, 'Check gear down and locked, cleared to land.' Even if you are flying a fixed-gear aircraft you will still get your landing clearance issued in this way, because it is simply a military SOP. It would not suggest that there was any problem in this case with having forgot to put the gear down.
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Midland63,
"check gear down and lock" words from tower is normal here at airports handling military traffic, and JOG, is an airbase... with a civilian enclave... At another airbase (with civilian ATC), it's "check gear down three greens" coming out for the milboys.
Magplug,
Garuda rushing an approach and not becoming stable is something which, though possible, seems unlikely, without other causes.
It seems morelikely that things were normal, then a flap malfunction, leaving them to land with little flap... The problem wasn't so much the lack of flap deployment, but the decision to land in JOG with that known flap (even 732s pilots wouldn't land their 732s in JOG with a flap15!), and also the differences between a normal approach and a flap15 approach added with the time of day/runway alignment.
A flap15 approach would give a nose higher than normal approach, it is extremely tempting to dip the nose down for a "better look", which would end up gaining a lot of speed thanks to the lower drag config, pull the nose up try to bleed off the speed, and repeat the whole thing again...
Add that with the sunglare, given that it was 7am and they were approaching into the sun. Furthermore, the threshold being above the surrounding terrain, with the runway above a bush-walled embankment with a river in front (no/little clearway before the runway), an upslope for the TDZ, but downhill until the end of the runway, can and has yielded visual illusions causing airplanes to come in high... Now in a flap15 config, that's not a good thing...
PK-KAR
"check gear down and lock" words from tower is normal here at airports handling military traffic, and JOG, is an airbase... with a civilian enclave... At another airbase (with civilian ATC), it's "check gear down three greens" coming out for the milboys.
Magplug,
Garuda rushing an approach and not becoming stable is something which, though possible, seems unlikely, without other causes.
It seems morelikely that things were normal, then a flap malfunction, leaving them to land with little flap... The problem wasn't so much the lack of flap deployment, but the decision to land in JOG with that known flap (even 732s pilots wouldn't land their 732s in JOG with a flap15!), and also the differences between a normal approach and a flap15 approach added with the time of day/runway alignment.
A flap15 approach would give a nose higher than normal approach, it is extremely tempting to dip the nose down for a "better look", which would end up gaining a lot of speed thanks to the lower drag config, pull the nose up try to bleed off the speed, and repeat the whole thing again...
Add that with the sunglare, given that it was 7am and they were approaching into the sun. Furthermore, the threshold being above the surrounding terrain, with the runway above a bush-walled embankment with a river in front (no/little clearway before the runway), an upslope for the TDZ, but downhill until the end of the runway, can and has yielded visual illusions causing airplanes to come in high... Now in a flap15 config, that's not a good thing...
PK-KAR
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This leaves 2 options, they couldn’t get the thing back up in the air due to malfunction or they made a bloody stupid decision. As for the comments from the pilots re wind etc etc, apparently that’s what they were telling the officials who then told the media. In saying that, I guess you cannot trust them.
Not just for their sakes (Garuda boys), but others who make a living out of having a pole between their legs or a stick to their side, I really hope this turns out to be some sort of mechanical failure and not pilot error.
Not just for their sakes (Garuda boys), but others who make a living out of having a pole between their legs or a stick to their side, I really hope this turns out to be some sort of mechanical failure and not pilot error.
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Magplug & Wesky,
I seriously doubt that they had this accident because they went in too fast and cannot reach Vref30+5 assuming the flaps were all working.
I've just reviewed the interview SCTV did with the GA Pilot's Assoc, and again, there was no part of the interview where the pilots claimed wind... they claimed "something pushed the aircraft"... not "windshear brought us down".
Whether this is pilot error or mechanical failure? It's possible that it's both. However, some are saying it's pilot error leading to mechanical failure (flaps not extending due to speed), and I tend to take that as a rare possibility, and it is more likely that it was mechanical malfunction leading to pilot error.
I'd like to raise another write off that happened on 24th Dec here in Indonesia, also involving a 734. According to NTSB Factual Report (id: DCA07WA017):
In this case, again, no emergency was transmitted, no malfunction were mentioned to the ATC, and the reports of "amazing speed" was noted...
It seems more like the case of a long visual final, early deployment to flap15, then the same thing as what happened to LIJ happened.
Now in the case of GA200, they were landing at runway 09, at 7am, straight into the low sun, at a higher than normal nose attitude (glare probably adds to the difficulty). At a runway where the threshold is higher than the preceeding terrain, and where the runway perimeter is only 25m from the threshold, preceeded by an elevated riverbank. The TDZ 09 itself is an upslope, but it goes downhill down to the last 100m of the runway at the end of 27, where it levels out. (Just for an idea, standing at 27, you won't be able to see the tail of a 737 at 09). Even under normal landing config, flights coming in tend to touchdown late. Colleagues flying to JOG said being low there is a bit risky, there's also a flyover on finals.
PK-KAR
I seriously doubt that they had this accident because they went in too fast and cannot reach Vref30+5 assuming the flaps were all working.
I've just reviewed the interview SCTV did with the GA Pilot's Assoc, and again, there was no part of the interview where the pilots claimed wind... they claimed "something pushed the aircraft"... not "windshear brought us down".
Whether this is pilot error or mechanical failure? It's possible that it's both. However, some are saying it's pilot error leading to mechanical failure (flaps not extending due to speed), and I tend to take that as a rare possibility, and it is more likely that it was mechanical malfunction leading to pilot error.
I'd like to raise another write off that happened on 24th Dec here in Indonesia, also involving a 734. According to NTSB Factual Report (id: DCA07WA017):
On December 24, 2006, at around 0050 UTC, a Boeing 737-400, registration PK-LIJ, operated by Lion Air departed runway 31 at Hasanuddin Airport, Makassar, Sulawesi, Indonesia. The flight was a scheduled domestic passenger flight from Jakarta carrying 157 passengers, 2 flight crew and 5 flight attendants. On arrival, the aircraft was executing a visual approach via a left downwind pattern to runway 31. The crew maneuvered in a close pattern due to proximity of terrain on under the base and final approach areas of runway 31. The weather was reported to be 10 km visibility (approximately 6 sm), surface wind calm, no clouds, and surface temperature 29 C. According to a written report from the crew, when they selected the flaps from 15 deg. to 30 deg. on final, they observed that the flaps indicator indicated a asymmetrical condition. According to the report, the crew re-selected the flaps back to 15 deg. and they elected to continue approach and landing. The report said that the crew referred to the QRH for the situation and they also checked the actual landing distance for flaps 15 deg. landing configuration. The captain was the pilot flying. According to ground witness reports, on landing the aircraft was not on centerline, it bounced twice, and swerved down the runway. The aircraft came to rest beyond the runway in the overrun area. The passengers were evacuated with no reports of injuries. According to a report from the local airport authority, the aircraft sustained substantial damage; the right main landing gear was detached, the left main gear protruded through the left wing structure, and some fuselage skin was wrinkled. There was a significant ground scar on the runway surface. The FDR and CVR has been removed and secured after the event.
It seems more like the case of a long visual final, early deployment to flap15, then the same thing as what happened to LIJ happened.
Now in the case of GA200, they were landing at runway 09, at 7am, straight into the low sun, at a higher than normal nose attitude (glare probably adds to the difficulty). At a runway where the threshold is higher than the preceeding terrain, and where the runway perimeter is only 25m from the threshold, preceeded by an elevated riverbank. The TDZ 09 itself is an upslope, but it goes downhill down to the last 100m of the runway at the end of 27, where it levels out. (Just for an idea, standing at 27, you won't be able to see the tail of a 737 at 09). Even under normal landing config, flights coming in tend to touchdown late. Colleagues flying to JOG said being low there is a bit risky, there's also a flyover on finals.
PK-KAR
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I know it's hard, but could we please wait for the official version?
PK-KAR said:
when they selected the flaps from 15 deg. to 30 deg. on final, they observed that the flaps indicator indicated a asymmetrical condition. According to the report, the crew re-selected the flaps back to 15 deg. and they elected to continue approach and landing. The report said that the crew referred to the QRH for the situation and they also checked the actual landing distance for flaps 15 deg. landing configuration
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Magplug,
Pilot error in reaction to the flap lockout I don't have any complaints on because that's where all this seems to point to. There seems to be a lot of parallels to the Garuda accident. Sorry, you picked a better word, pilot error precipitated by flap lock-out
And that to me is a lot more believable than
Cheers,
PK-KAR
Pilot error in reaction to the flap lockout I don't have any complaints on because that's where all this seems to point to. There seems to be a lot of parallels to the Garuda accident. Sorry, you picked a better word, pilot error precipitated by flap lock-out
And that to me is a lot more believable than
The approach was rushed, to the extent that normal landing flap and Vref(30)+5 was not achieved.
PK-KAR
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Waiting for the offical report is to easy. It is quite clear pilot error made a part of this situation - simple as that.
On a side note, good to see a mod made an edit to my post?... The pic of flap 30 is still avbl
On a side note, good to see a mod made an edit to my post?... The pic of flap 30 is still avbl
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Quote from another pilot's forum....in response to discussion about Yogo's runway length and condition......
"The information we received in an email yesterday from our safety manager up here at XXXXX (local airline) is that there was no flap malfunction but the FO couldn't get the flap out because of the limit speed. The aircraft touched down in a flat attitude at 204kts with Flap 5. From pilot interviews the FO had told the captain to go around twice but the captain continued.
I guess performance figures wont help much if that is the case heh?"
Now I assume that "couldn't get the flap out" means the FO did not select the flap because of the limit. There is only a system activated limit on the Flap 40 setting. Flaps wont run to 40 or flaps will return to 30 above 158 (300) or 162kts (400)
If these facts prove to be the case the obvious question is to why did the PIC continue????????????? Human factors strike again?????
A black day for aviation professionals???.
"The information we received in an email yesterday from our safety manager up here at XXXXX (local airline) is that there was no flap malfunction but the FO couldn't get the flap out because of the limit speed. The aircraft touched down in a flat attitude at 204kts with Flap 5. From pilot interviews the FO had told the captain to go around twice but the captain continued.
I guess performance figures wont help much if that is the case heh?"
Now I assume that "couldn't get the flap out" means the FO did not select the flap because of the limit. There is only a system activated limit on the Flap 40 setting. Flaps wont run to 40 or flaps will return to 30 above 158 (300) or 162kts (400)
If these facts prove to be the case the obvious question is to why did the PIC continue????????????? Human factors strike again?????
A black day for aviation professionals???.
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Quote from another pilot's forum....in response to discussion about Yogo's runway length and condition......
"The information we received in an email yesterday from our safety manager up here at XXXXX (local airline) is that there was no flap malfunction but the FO couldn't get the flap out because of the limit speed. The aircraft touched down in a flat attitude at 204kts with Flap 5. From pilot interviews the FO had told the captain to go around twice but the captain continued.
"The information we received in an email yesterday from our safety manager up here at XXXXX (local airline) is that there was no flap malfunction but the FO couldn't get the flap out because of the limit speed. The aircraft touched down in a flat attitude at 204kts with Flap 5. From pilot interviews the FO had told the captain to go around twice but the captain continued.
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the FO couldn't get the flap out because of the limit speed
Company SOP 1:PIlots cant call for flap 1 until speed is below 220.Boeing built the aircraft and they clearly state 250.Take a 10 knot buffer and youve got 240.
Company SOP 2:Fly at flaps 1 speed when with flaps 1 selected.In a normal approach,no problem.But under all circumstances?
Company SOP 3:Capture the Localizer and then arm the APP mode.1 dot,gear down flaps 15 blah blah blah.And what if you cant take flaps because your speed is too high?Are you still going to arm APP?
Blind standardization,over-reliance on automation and a failure to think outside the book.Welcome to the modern cockpit.Indonesia.Europe.US.Wherever.
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To offer an alternative to magplug's conspiracy hypothesis.
A friend told me that a friend etc... tried to book on 7 mar CGK-YOG. Was told 'cannot travel on this date'. 6 mar or 8 mar OK. So said pax went on 6 mar. Then GA200 duly skittled off the end, with a load of aussie diplomats (oxymoron?) on board. Downer was meant to be on board but got delayed.
The truth? Dunno, but don't let it spoil a good story.
A friend told me that a friend etc... tried to book on 7 mar CGK-YOG. Was told 'cannot travel on this date'. 6 mar or 8 mar OK. So said pax went on 6 mar. Then GA200 duly skittled off the end, with a load of aussie diplomats (oxymoron?) on board. Downer was meant to be on board but got delayed.
The truth? Dunno, but don't let it spoil a good story.
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Just to introduce a cultural dimension to the debate on CRM aspects here, is it possible that the Captain would be conscious of losing face in front of the F/O. Having screwed up (rushed) the approach to such an extent that they arrived at 200+ kts in F5, was the Captain determined to press home the approach regardless because he did not want to lose face?
....This is a good talking point for F/O's.... What would you do if you were faced with such a situation?
....This is a good talking point for F/O's.... What would you do if you were faced with such a situation?
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Re-entry,
Dunno which agent you called, but I booked 2 pax on GA200 on 07Mar07 and 7 on the flight after... booked the day before.
Magplug,
Discussions with people who know the Captain revealed that the Captain is procedural, and tends to let the F/O help in the decision making process, as in, not the tyro/ego type with huge loss of face issues... This is why everyone is interested... if he's not that type, how on earth can this happen? If he did press on regardless as per that rumour, why? Why did he leave his consistent behaviour then? All these are questions bugging the minds of those who knows what the captain is like.
The F/O however, is a different story, and only joined Garuda in 2005...
PK-KAR
A friend told me that a friend etc... tried to book on 7 mar CGK-YOG. Was told 'cannot travel on this date'.
Magplug,
Discussions with people who know the Captain revealed that the Captain is procedural, and tends to let the F/O help in the decision making process, as in, not the tyro/ego type with huge loss of face issues... This is why everyone is interested... if he's not that type, how on earth can this happen? If he did press on regardless as per that rumour, why? Why did he leave his consistent behaviour then? All these are questions bugging the minds of those who knows what the captain is like.
The F/O however, is a different story, and only joined Garuda in 2005...
PK-KAR
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people who know the Captain revealed that the Captain is procedural, and tends to let the F/O help in the decision making process, as in, not the tyro/ego type with huge loss of face issues...
There might yet be a greater dimension to this accident.
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The F/O was fresh from flight school and just joined Garuda in 2005. It is likely that he's also just got his second bar not long ago.
It would be interesting if there are any external factors affecting the captain... As to the RYR Captain, interesting that I just read an article on it 2 nights ago... in that case it was more like the captain returning to work "too early" because he wouldn't think the company would give him extra time off... But then, I dunno much about that case...
We'll find out more on the GA case as time goes by...
Interestingly, Garuda was rated as class II by the govt. last night (with Adam in class III, not surprisingly)... and it was stated that the sole reason of GA entering Class II because of this crash... "accident free" record was required for class I.
Bummer for GA indeed!
PK-KAR
It would be interesting if there are any external factors affecting the captain... As to the RYR Captain, interesting that I just read an article on it 2 nights ago... in that case it was more like the captain returning to work "too early" because he wouldn't think the company would give him extra time off... But then, I dunno much about that case...
We'll find out more on the GA case as time goes by...
Interestingly, Garuda was rated as class II by the govt. last night (with Adam in class III, not surprisingly)... and it was stated that the sole reason of GA entering Class II because of this crash... "accident free" record was required for class I.
Bummer for GA indeed!
PK-KAR
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PK-KAR, what you say (immediately above) about the record being rated II as a result of the no longer crash-free record is indeed ironic.
Insurance companies have another perspective. People often say about misfortune that "it might have happened anywhere" or "it could have happened to anyone", but the opposing perspective is simply that it did not. From mountains of coldly quantitative statistics, insurance underwriters infer an eerie sense of a working mechanism which might not be quantitative after all.
In a more positive application, we say there is a definite difference between a man who actually takes a trip—you might like to say, a man who actually becomes a pilot—and a man who projects the dream or the intention, but never really lives it out. In that application, the concept is rather pleasing.
How many examples of misfortune do we need to feel nervous? Well, one is often all it takes, because one establishes the precedent. An elderly person falls for no apparent reason, just once, and loses confidence in herself. It is all inductive reasoning, and it is not at all air-tight, but it is all we have.
Cross-country bus drivers have in the past risked their careers over single accidents—I don't know if the policy still stands or not. The captain of the Titanic had an imperfect record. Who knows if it mattered or not?
Nature, however, seems to side with the insurance companies. One mistake, one single mistake, and people die. They might not have, but they did; and it might have happened on any airline, but it happened on this one; and it could have happened anywhere, but it happened here. It might have happened to anyone else's fathers and sisters and children, but. . . .
Insurance companies have another perspective. People often say about misfortune that "it might have happened anywhere" or "it could have happened to anyone", but the opposing perspective is simply that it did not. From mountains of coldly quantitative statistics, insurance underwriters infer an eerie sense of a working mechanism which might not be quantitative after all.
In a more positive application, we say there is a definite difference between a man who actually takes a trip—you might like to say, a man who actually becomes a pilot—and a man who projects the dream or the intention, but never really lives it out. In that application, the concept is rather pleasing.
How many examples of misfortune do we need to feel nervous? Well, one is often all it takes, because one establishes the precedent. An elderly person falls for no apparent reason, just once, and loses confidence in herself. It is all inductive reasoning, and it is not at all air-tight, but it is all we have.
Cross-country bus drivers have in the past risked their careers over single accidents—I don't know if the policy still stands or not. The captain of the Titanic had an imperfect record. Who knows if it mattered or not?
Nature, however, seems to side with the insurance companies. One mistake, one single mistake, and people die. They might not have, but they did; and it might have happened on any airline, but it happened on this one; and it could have happened anywhere, but it happened here. It might have happened to anyone else's fathers and sisters and children, but. . . .