Indonesian B737 runway overrun/crash
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Indonesia's record
This (Flight International nearly a month ago) provides a perspective on Indonesia's airline safety record. Look behind the statistics for the truth:
http://www.flightglobal.com/articles...to-change.html
Apologies if someone linked it before.
http://www.flightglobal.com/articles...to-change.html
Apologies if someone linked it before.
Centaurus ‘A fine ideal but not realistic’
Achieving an ideal is always difficult, but we need ideals; they are an aim – the objective of improving safety. Without ideals then you may as well accept the status quo in those countries / operators who appear to be ‘less safe’ when judged by our ideals.
One question that this line of thought raises is whether our ideals should be applied to those countries / operators. We should ask if our ‘ideal’ operating / training methods are suitable for their culture – why is our way the best, will our way ever work ‘over there’.
Which is the dominant culture in this thread and what type of culture is depicted?
theamrad ‘then to hell with their perceptions’
Surely a problem with culture is that it inbreeds perception as subconscious bias. These biases, shame – loss of face, are part of a way of life, education, business, etc.
If we take the view that ‘their’ culture is not capable of significant change – meeting ‘our’ ideals, then the alternative is to provide defences elsewhere. As Prof Reason indicates, safety problems originate in the organisation, and changes there can protect operators from themselves – from their culture.
If the problem is P1 dominance, (P1 not receptive, P2 not assertive, or both P1/P2 in error); then a solution could be to design an aircraft that is able to protect the crew from hazardous activity emanating from their culture. In this sense the Airbus philosophy has great merit, particularly where the P1 problem can occur in any culture.
An alternative solution is to put the functional excellence of P2 – the crosscheck/monitor and alerting functions, into a box. Humans tend to respect a computed output more than another human, particularly where the commuter provides a solution to the error. However, even this has human problems as seen with crews ignoring GPWS and more recently EGPWS. The natural progression would be to automate, to remove the human of whatever culture / error prone disposition, from the flying / decision loop. Automatic EGPWS, ACAS, and windshear manoeuvring is possible, but might face some professional culture issues before acceptance.
Clearly, in the immediate future, automation or use of alerting technology cannot provide the ideal that the industry seeks; thus back to Centaurus / the top of my post – achieving the ideal is difficult.
For a change we could try to see the problem from ‘their’ perspective. Is there anything within their culture that could be used to improve safety – how can flying a GA be presented as something of honour, to be sought, to be rewarded?
But we still strive for this in our culture; we have CRM and we have overruns. So what is the difference – Burbank, Toronto, Midway, – the number of fatalities !!
Many of the contributing factors in these accidents were organisational, thus in whichever culture we reside or from whichever viewpoint we take, perhaps organisational changes should be explored in parallel with those aimed at the end user; look higher up in the organisation (Operator / Regulator / Government) so that change will address the poor overall safety levels indicated in the statistics. But equally, and yet again as presented by Prof Reason, don’t let the pendulum swing too far towards the organisation; individuals (pilots) must hold some accountability.
shortfinals there is no truth in statistics – in front or behind them, only a viewpoint; it is the alternative viewpoints that are important.
Achieving an ideal is always difficult, but we need ideals; they are an aim – the objective of improving safety. Without ideals then you may as well accept the status quo in those countries / operators who appear to be ‘less safe’ when judged by our ideals.
One question that this line of thought raises is whether our ideals should be applied to those countries / operators. We should ask if our ‘ideal’ operating / training methods are suitable for their culture – why is our way the best, will our way ever work ‘over there’.
Which is the dominant culture in this thread and what type of culture is depicted?
theamrad ‘then to hell with their perceptions’
Surely a problem with culture is that it inbreeds perception as subconscious bias. These biases, shame – loss of face, are part of a way of life, education, business, etc.
If we take the view that ‘their’ culture is not capable of significant change – meeting ‘our’ ideals, then the alternative is to provide defences elsewhere. As Prof Reason indicates, safety problems originate in the organisation, and changes there can protect operators from themselves – from their culture.
If the problem is P1 dominance, (P1 not receptive, P2 not assertive, or both P1/P2 in error); then a solution could be to design an aircraft that is able to protect the crew from hazardous activity emanating from their culture. In this sense the Airbus philosophy has great merit, particularly where the P1 problem can occur in any culture.
An alternative solution is to put the functional excellence of P2 – the crosscheck/monitor and alerting functions, into a box. Humans tend to respect a computed output more than another human, particularly where the commuter provides a solution to the error. However, even this has human problems as seen with crews ignoring GPWS and more recently EGPWS. The natural progression would be to automate, to remove the human of whatever culture / error prone disposition, from the flying / decision loop. Automatic EGPWS, ACAS, and windshear manoeuvring is possible, but might face some professional culture issues before acceptance.
Clearly, in the immediate future, automation or use of alerting technology cannot provide the ideal that the industry seeks; thus back to Centaurus / the top of my post – achieving the ideal is difficult.
For a change we could try to see the problem from ‘their’ perspective. Is there anything within their culture that could be used to improve safety – how can flying a GA be presented as something of honour, to be sought, to be rewarded?
But we still strive for this in our culture; we have CRM and we have overruns. So what is the difference – Burbank, Toronto, Midway, – the number of fatalities !!
Many of the contributing factors in these accidents were organisational, thus in whichever culture we reside or from whichever viewpoint we take, perhaps organisational changes should be explored in parallel with those aimed at the end user; look higher up in the organisation (Operator / Regulator / Government) so that change will address the poor overall safety levels indicated in the statistics. But equally, and yet again as presented by Prof Reason, don’t let the pendulum swing too far towards the organisation; individuals (pilots) must hold some accountability.
shortfinals there is no truth in statistics – in front or behind them, only a viewpoint; it is the alternative viewpoints that are important.
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Uhmmmmm,
YOGYAKARTA (Antara): The Indonesian National Transportation Safety Commission (KNKT) is later this week scheduled to reexamine the wreckage of the Garuda jetliner which overshot the runway and caught fire at Adisutjipto airport last March 7, a spokesman said.
"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.
He also denied media reports on Monday that the plane's pilot and co-pilot had an argument with each other about the plane's speed moments before the accident occurred.
"There was no argument between the pilot and co-pilot. What happened was there was coordination between them about flight safety," Tumenggung said.
Meanwhile, Transportation Minister Hatta Rajasa on Monday also denied there was an argument between the Garuda plane's pilot an co-pilot shortly before the tragedy.
According to media reports, the result of cockpit voice recordings which were investigated in Australia showed that the co-pilot wanted the pilot to go around again instead of landing at Yogyakarta's Adisutjipto airport on March 7.
Source:
http://www.thejakartapost.com/detail...3165204&irec=2
YOGYAKARTA (Antara): The Indonesian National Transportation Safety Commission (KNKT) is later this week scheduled to reexamine the wreckage of the Garuda jetliner which overshot the runway and caught fire at Adisutjipto airport last March 7, a spokesman said.
"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.
He also denied media reports on Monday that the plane's pilot and co-pilot had an argument with each other about the plane's speed moments before the accident occurred.
"There was no argument between the pilot and co-pilot. What happened was there was coordination between them about flight safety," Tumenggung said.
Meanwhile, Transportation Minister Hatta Rajasa on Monday also denied there was an argument between the Garuda plane's pilot an co-pilot shortly before the tragedy.
According to media reports, the result of cockpit voice recordings which were investigated in Australia showed that the co-pilot wanted the pilot to go around again instead of landing at Yogyakarta's Adisutjipto airport on March 7.
Source:
http://www.thejakartapost.com/detail...3165204&irec=2
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Alf5071h – I think you may have misunderstood my reference to “their perceptions” – I apologise if it was a bit cryptic. What I meant was a reference to your remarks about factors involving loss of face etc. Just the point that public perceptions should be the last consideration when a GA is appropriate – of course passenger comfort is another ideal – but safety is paramount.
Since you’ve mentioned cultural issues – my thinking is always going to be down the line of training in best CRM practice – and the insistence on its use. 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.
I’m not quite sure if I’d agree with you on this point. Aside from blatantly ignoring cautions or warnings – if we look at the philosophy behind the design of EGPWS – to eliminate the generation of false alerts to the degree which is reasonable, while still providing an excellent system – we can still get a lot of those false alerts. And every false warning degrades the system (system in terms of human-machine interaction). This is also mirrored in the number of ‘false/spurious’ TCAS RA events in European RVSM in recent years – one of which triggered a ‘genuine’ conflict and secondary RA with a third aircraft. So automation doesn’t really offer a solution on its own.
Another knockdown in terms of using automation to deal with problems comes from the potential reliability of systems. We only have to look at regulations governing instrument landing systems (both ground and aircraft based) to see the consequences of system failure rates – and the limitations in use which arise from those rates (failure ‘unlikely’, ‘extremely unlikely’, etc). The additional effects which result when we consider whether a system is fail passive or fail active. Etc, etc.
‘P1 not receptive, P2 not assertive’ – well although I would have to admit it’s a lot more likely as a cultural factor in Indonesia – I agree that nowhere is completely immune from it, particularly the P1 not receptive (for example RA at Cork).
Well.... if this turns out to be the way it's shaping up to be. In the case of an overrun - the final outcome is down to luck - exactly what is at the end of the runway. If GA200 had touched down at Jakarta - the consequences may have been nose gear and engine damage, with injuries only. Similarly, if that garage forecourt at Burbank had been nice solid concrete office building....... . Reminds me of the Virgin train spill recently: one fatality, a good few injuries, a few carraiges derailed - but looking pretty good considering. But then it didn't happen in a built-up area - there were no buildings to collide with!!!
Since you’ve mentioned cultural issues – my thinking is always going to be down the line of training in best CRM practice – and the insistence on its use. 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.
An alternative solution is to put the functional excellence of P2 – the crosscheck/monitor and alerting functions, into a box. Humans tend to respect a computed output more than another human, particularly where the commuter provides a solution to the error. However, even this has human problems as seen with crews ignoring GPWS and more recently EGPWS.
I’m not quite sure if I’d agree with you on this point. Aside from blatantly ignoring cautions or warnings – if we look at the philosophy behind the design of EGPWS – to eliminate the generation of false alerts to the degree which is reasonable, while still providing an excellent system – we can still get a lot of those false alerts. And every false warning degrades the system (system in terms of human-machine interaction). This is also mirrored in the number of ‘false/spurious’ TCAS RA events in European RVSM in recent years – one of which triggered a ‘genuine’ conflict and secondary RA with a third aircraft. So automation doesn’t really offer a solution on its own.
Another knockdown in terms of using automation to deal with problems comes from the potential reliability of systems. We only have to look at regulations governing instrument landing systems (both ground and aircraft based) to see the consequences of system failure rates – and the limitations in use which arise from those rates (failure ‘unlikely’, ‘extremely unlikely’, etc). The additional effects which result when we consider whether a system is fail passive or fail active. Etc, etc.
‘P1 not receptive, P2 not assertive’ – well although I would have to admit it’s a lot more likely as a cultural factor in Indonesia – I agree that nowhere is completely immune from it, particularly the P1 not receptive (for example RA at Cork).
So what is the difference – Burbank, Toronto, Midway, – the number of fatalities !!
For a change we could try to see the problem from ‘their’ perspective. Is there anything within their culture that could be used to improve safety – how can flying a GA be presented as something of honour, to be sought, to be rewarded?
theamrad we are thinking along similar lines, but with differences in detail.
“… public perceptions should be the last consideration when a GA is appropriate – of course passenger comfort is another ideal – but safety is paramount,”
I agree, but do we make these considerations on every flight – some would argue yes, but other evidence suggests that the judgments made in everyday operations are flawed and thus might become the norm (LOSA report - 11% of all approaches are unstable). Thus, the need for an ‘unsafe act’ becomes the ‘latent factor’; it just has to wait for the particular situation and failure to perceive/act to complete the accident path.
“… cultural issues – my thinking is always going to be down the line of training in best CRM practice – and the insistence on its use.”
I agree, but when viewed in conjunction with “what is the point of having someone in the right-hand seat” (Centaurus), then the value of CRM is questionable and the difficulties of training, at least behavioral shaping, are significant – see the link about ‘asking for help’ below, and the difficulties of encouraging teamwork … “after repeatedly trained in school at every level … to "do your own work", by adulthood the socialization is deeply embedded, … ” – failure to work together.
“P1 not receptive” … surely culture only shapes the human factor, it isn’t the human factor?
As for systems, particularly EGPWS, I ride a high hobby horse. See the addendum to ‘Celebrating TAWS Saves’ (via ICAO) and ‘Last line of defence’ (via FSF).
GPWS, the computer, did not suffer ‘false alerts’. The design was limited and overall system had weaknesses, which EGPWS has overcome and is very reliable – it does not have false alerts. Every alert must be respected; only hindsight / subsequent investigation will determine the validity of the event. The associated systems (FMS, Rad Alt, etc) and the human remain the weak links. Some similarities with organizational systems and their components ?
Automation and system reliability is matter of trust; we trust an automatic GA, which is not necessarily a fail active system. The technology exists to couple EGPWS to the autopilot GA mode. If the auto pilot (or FD) changed to GA, I suggest that few pilots would override the action – it triggers the necessary change in thought – situation assessment – realization of the need for alternative action. People are already working on coding the parameters of the stabilized approach into a warning system, automation is next. An approach warning system (deviation from a stabilized approach) would be threat and error awareness system, much the same as EGPWS is when considered as a constant display of the margins from terrain.
Centaurus We too are in agreement.
I have been there, done a little type conversion training, and made no progress with culture – perhaps leading to the desire to understand what could be done from their viewpoint as opposed to mine. The summary of my visit was that there were pilots who could operate the aircraft and those who could not – a disturbing, but dated observation. 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.
Re "Real Men Don't Go Around”. I note the thread.
See ‘asking for help’ in the blog at – cscwteam - ******** - .com at archive 2006 08 27 (Sept 1, High reliability asking for help – after Comair) Sorry no link available – couple the bits together or Google.
There are also some interesting follow on links ‘System blindness, safety culture, and accidents’ and ‘Secrets of High-Reliability Organization’.
Also see:-
Archive 2006 09 05 (TEM Sept 5) “It tries to change the way we think in the cockpit by taking more of a big picture outlook on what is going on, slowing down what we do, and communicating concerns to find threats and errors before they cause a violation, incident, or accident”.
and
“For pilots, there is no "fog caused accident" exemption (car). There is only "the pilot in command continued operations into conditions beyond his skill and experience, …” (Drivers Aug 27)
“… public perceptions should be the last consideration when a GA is appropriate – of course passenger comfort is another ideal – but safety is paramount,”
I agree, but do we make these considerations on every flight – some would argue yes, but other evidence suggests that the judgments made in everyday operations are flawed and thus might become the norm (LOSA report - 11% of all approaches are unstable). Thus, the need for an ‘unsafe act’ becomes the ‘latent factor’; it just has to wait for the particular situation and failure to perceive/act to complete the accident path.
“… cultural issues – my thinking is always going to be down the line of training in best CRM practice – and the insistence on its use.”
I agree, but when viewed in conjunction with “what is the point of having someone in the right-hand seat” (Centaurus), then the value of CRM is questionable and the difficulties of training, at least behavioral shaping, are significant – see the link about ‘asking for help’ below, and the difficulties of encouraging teamwork … “after repeatedly trained in school at every level … to "do your own work", by adulthood the socialization is deeply embedded, … ” – failure to work together.
“P1 not receptive” … surely culture only shapes the human factor, it isn’t the human factor?
As for systems, particularly EGPWS, I ride a high hobby horse. See the addendum to ‘Celebrating TAWS Saves’ (via ICAO) and ‘Last line of defence’ (via FSF).
GPWS, the computer, did not suffer ‘false alerts’. The design was limited and overall system had weaknesses, which EGPWS has overcome and is very reliable – it does not have false alerts. Every alert must be respected; only hindsight / subsequent investigation will determine the validity of the event. The associated systems (FMS, Rad Alt, etc) and the human remain the weak links. Some similarities with organizational systems and their components ?
Automation and system reliability is matter of trust; we trust an automatic GA, which is not necessarily a fail active system. The technology exists to couple EGPWS to the autopilot GA mode. If the auto pilot (or FD) changed to GA, I suggest that few pilots would override the action – it triggers the necessary change in thought – situation assessment – realization of the need for alternative action. People are already working on coding the parameters of the stabilized approach into a warning system, automation is next. An approach warning system (deviation from a stabilized approach) would be threat and error awareness system, much the same as EGPWS is when considered as a constant display of the margins from terrain.
Centaurus We too are in agreement.
I have been there, done a little type conversion training, and made no progress with culture – perhaps leading to the desire to understand what could be done from their viewpoint as opposed to mine. The summary of my visit was that there were pilots who could operate the aircraft and those who could not – a disturbing, but dated observation. 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.
Re "Real Men Don't Go Around”. I note the thread.
See ‘asking for help’ in the blog at – cscwteam - ******** - .com at archive 2006 08 27 (Sept 1, High reliability asking for help – after Comair) Sorry no link available – couple the bits together or Google.
There are also some interesting follow on links ‘System blindness, safety culture, and accidents’ and ‘Secrets of High-Reliability Organization’.
Also see:-
Archive 2006 09 05 (TEM Sept 5) “It tries to change the way we think in the cockpit by taking more of a big picture outlook on what is going on, slowing down what we do, and communicating concerns to find threats and errors before they cause a violation, incident, or accident”.
and
“For pilots, there is no "fog caused accident" exemption (car). There is only "the pilot in command continued operations into conditions beyond his skill and experience, …” (Drivers Aug 27)
Last edited by alf5071h; 5th Apr 2007 at 01:36.
There was no argument between the pilot and co-pilot. What happened was there was coordination between them about flight safety,"
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Go Around Culture
Way back in time, I had an interview with Korean Air. The sim (MD-80) was a real handful and a couple of times I came out off centreline on a non precision approach.
In the debrief, I was told "We really need pilots here but we want people who can land! Why do you always go around (this in a shouting tone) ? You turn left... you turn right... and you land!"
This followed a session in which two check pilots behind were smoking all through and hands would come from nowhere and retune nav aids over my shoulder etc. I needed a job too but decided that selected or not I wouldn't be going there.
Culture or the lack of it is a major factor in pilot behaviour - the pilot has the last word, however.
FC.
In the debrief, I was told "We really need pilots here but we want people who can land! Why do you always go around (this in a shouting tone) ? You turn left... you turn right... and you land!"
This followed a session in which two check pilots behind were smoking all through and hands would come from nowhere and retune nav aids over my shoulder etc. I needed a job too but decided that selected or not I wouldn't be going there.
Culture or the lack of it is a major factor in pilot behaviour - the pilot has the last word, however.
FC.
From today's Sydney Morning Herald. Seems to sum up the "known" facts thus far, (with the predictable journalistic errors).
http://www.smh.com.au/news/world/pla...366474352.html
http://www.smh.com.au/news/world/pla...366474352.html
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.
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)
You can't underestimate the power of velocity squared!
I wonder if 410kph was a g/s, IAS or TAS?
Either way 410kph = 220kts & the tyre limiting speed is usually 195kts.
Does anybody have a link to the preliminary accident report?
Either way 410kph = 220kts & the tyre limiting speed is usually 195kts.
Does anybody have a link to the preliminary accident report?
Last edited by CaptainSandL; 7th Apr 2007 at 10:56.
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Fire engines and rescue vehicles were unable to reach the crash site quickly and were not properly equipped.
The weather was calm, contradicting the pilot's claims of a massive down draught.
failure of emergency services to respond quickly could have contributed to the crash
Does anybody have a link to the preliminary accident report?
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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.
---
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.
---
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.
---
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.
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.
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.
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.
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.
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.
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
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.
---
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.
---
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.
---
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.
Would the rating system have appeared if Australian officials hadn't been onboard, with the resultant increased interest from outside Indonesia?
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
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.
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.
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.
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
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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Having just gone through this topic for another reason just a few late questions/observations:
Craig Freir - CRM is a wasted a training culture in much of the world, if your company DOES NOT have a clear explanation of the required action/responses (yes, yet again "the pyramid" or similar) all the training in the world will not, generally, over-ride the cultural bottom line simply because you know you do not have the implicit, required legal obligation of support from the company.
A nice quote along the lines of "CRM is good and helps safety" is as much as you get for CRM in Ops Mans in many companies; if you have something far more defined be grateful because you know where you stand legally should you ever have to explain yourself to a court of inquiry!
Others:
- assuming my "classic" understanding is the same as others I have been landing 737-3/4 predominantely at Flap 30, 40 when required by operational circumstances; the ops manual reflects that Flaps 15, 30, 40 are Boeing certified landing flaps.
Someone says there is no "Flaps 30"
Having done same for 20 years should I be taken out and shot? (the wife would obviously suggest it's a damn fine idea but could we please rise above that?)
- further on the classic there is only boeing designed relief on overspeed with Flaps 40 set retracting to Flaps 30 (which, as alleged above by others, does not exist
), any other "relief" would be from the aerodynamics of the pilot "fcuking up speed wise" and not a boeing design nor recommendation.
Am I wrong??
Craig Freir - CRM is a wasted a training culture in much of the world, if your company DOES NOT have a clear explanation of the required action/responses (yes, yet again "the pyramid" or similar) all the training in the world will not, generally, over-ride the cultural bottom line simply because you know you do not have the implicit, required legal obligation of support from the company.
A nice quote along the lines of "CRM is good and helps safety" is as much as you get for CRM in Ops Mans in many companies; if you have something far more defined be grateful because you know where you stand legally should you ever have to explain yourself to a court of inquiry!
Others:
- assuming my "classic" understanding is the same as others I have been landing 737-3/4 predominantely at Flap 30, 40 when required by operational circumstances; the ops manual reflects that Flaps 15, 30, 40 are Boeing certified landing flaps.
Someone says there is no "Flaps 30"
Having done same for 20 years should I be taken out and shot? (the wife would obviously suggest it's a damn fine idea but could we please rise above that?)
- further on the classic there is only boeing designed relief on overspeed with Flaps 40 set retracting to Flaps 30 (which, as alleged above by others, does not exist
), any other "relief" would be from the aerodynamics of the pilot "fcuking up speed wise" and not a boeing design nor recommendation.Am I wrong??
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Someone says there is no "Flaps 30" .........
(which, as alleged above by others, does not exist )
.........(which, as alleged above by others, does not exist
)
. As far as your comments about CRM are concerned - I tend to agree with you. Bearing in mind the previous comments from those with an instructor's viewpoint - there is little point in lambasting pilots during simulator training, unless the importance of CRM becomes part of the entire organisations operating culture.
-----------------------------------------------------------
PK-KAR - that is quite a mouthful!
Although I'm not as sure on the classics (I presume same/similar),the NG's aren't exactly renowned for "aerobraking" ability with flaps 1 and 5 (beside the point that it's not 'recommended' anyway). So if on or near to the glide at 2,500' AGL - 272 kts IAS wasn't going to cut it, at least with small flap deployment and no speedbrake!
Just wondering if you know if the report mentions what the flap setting was at ground contact, or if the speedbrake was up during any portion of the descent? Maybe flap setting is one of the 'lost' parameters?
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Theamrad,
It is one heck of a mouthful...
Flaps on touchdown was at 5, not sure if it was based on lever selection or gauge/actual. If I remember correctly, speedbrakes weren't deployed on the last 4000ft... but the speedbrake data is based on speedbrake lever position... it deployed on the 1st touchdown until the last 5 secs of the recording, after reversers were stowed and "some" positive throttle movement.
I guess I have to reconstruct the path based on what I remember to give us a better idea on the path on the last 4000ft... But, in my opinion is of little use if we do not have the data since leaving cruise level...
PK-KAR
It is one heck of a mouthful...
Flaps on touchdown was at 5, not sure if it was based on lever selection or gauge/actual. If I remember correctly, speedbrakes weren't deployed on the last 4000ft... but the speedbrake data is based on speedbrake lever position... it deployed on the 1st touchdown until the last 5 secs of the recording, after reversers were stowed and "some" positive throttle movement.
I guess I have to reconstruct the path based on what I remember to give us a better idea on the path on the last 4000ft... But, in my opinion is of little use if we do not have the data since leaving cruise level...
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coverage of yogya crash
You should be a little patient with journalists unfamiliar with aviation attempting to accurately dissect events, especially before assuming errors and "editorialising".
Theamrad in particular has taken half sentences from the SMH to poke fun at the coverage of the preliminary report.
He posts:
Quote:
Fire engines and rescue vehicles were unable to reach the crash site quickly and were not properly equipped.
Not equiped with what? Warp drive? It did come to rest in a rice field!
Quote:
The weather was calm, contradicting the pilot's claims of a massive down draught.
Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread!
Quote:
failure of emergency services to respond quickly could have contributed to the crash
mmmmm - yeah, I can see the logical progression there.
1. the report criticises the type of foam and hoses available, and the lack of an internal access road to the crash site.
2. Please tell me more about the winds, I couldn't find what he was referring to on the thread.
3. the actual story stated the 60 metre safety run-off ANd the failure of emergency services....could have contributed to the crash AND the number of fatalities
Theamrad in particular has taken half sentences from the SMH to poke fun at the coverage of the preliminary report.
He posts:
Quote:
Fire engines and rescue vehicles were unable to reach the crash site quickly and were not properly equipped.
Not equiped with what? Warp drive? It did come to rest in a rice field!
Quote:
The weather was calm, contradicting the pilot's claims of a massive down draught.
Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread!
Quote:
failure of emergency services to respond quickly could have contributed to the crash
mmmmm - yeah, I can see the logical progression there.
1. the report criticises the type of foam and hoses available, and the lack of an internal access road to the crash site.
2. Please tell me more about the winds, I couldn't find what he was referring to on the thread.
3. the actual story stated the 60 metre safety run-off ANd the failure of emergency services....could have contributed to the crash AND the number of fatalities
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The preliminary report is only obliged to cover the factual information... as far as I know.
Although I do not agree with the NTSC findings in terms of criticizing the emergency equipment, it is their right to do so. The main problem is that bloody road crossing it. It should be recommended that faster access from the inside of the airport be made available to the area. Had this crash happened on runway 27 instead, we'd definitely see more fatalities!
In my personal opinion, the lack of runway end safety area did not cause the crash, but contributed to deaths in the accident.
Now as to:
I have been trying to reverify this over the last few days... It now appears that the sources have corrected me...
Under 1000ft, 2 reminders were made by the F/O. On the 1st... The F/O said: "shouldn't we go around?", the Captain responded by saying "Wait, let's try", on the second one, the F/O said the same thing and did not hear a response from the captain.
There is however, another comment made by the F/O before the two I mentioned, which still needs confirmation.
Now I'm getting sick and tired of this downdraft business. Can someone point me as to where the pilots claimed of a downdraft? All I can find is the interview with the chief of GA pilot's association where he said "the captain felt as if something pushed the aircraft very strongly in the last moments before touchdown." The interviewer then said, "WHat could that be?" The chief responded by saying "we dunno, maybe a downdraft?"
PK-KAR
Although I do not agree with the NTSC findings in terms of criticizing the emergency equipment, it is their right to do so. The main problem is that bloody road crossing it. It should be recommended that faster access from the inside of the airport be made available to the area. Had this crash happened on runway 27 instead, we'd definitely see more fatalities!
In my personal opinion, the lack of runway end safety area did not cause the crash, but contributed to deaths in the accident.
Now as to:
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.
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.
Under 1000ft, 2 reminders were made by the F/O. On the 1st... The F/O said: "shouldn't we go around?", the Captain responded by saying "Wait, let's try", on the second one, the F/O said the same thing and did not hear a response from the captain.
There is however, another comment made by the F/O before the two I mentioned, which still needs confirmation.
Quote:
The weather was calm, contradicting the pilot's claims of a massive down draught.
Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread!
The weather was calm, contradicting the pilot's claims of a massive down draught.
Accuracy again - obviously the Sydney Morning Herald has not had the benefit of browsing this thread!
PK-KAR
Many questions - no answers
I wonder if the investigation will ever be able to determine why the Captain failed to discontinue the approach; unless of course, with hindsight, he is able to provide a plausible explanation – enabling us to have an understanding of the event.
There appears to be similarities with the accidents in Bangkok (747) and Burbank (737). In these events, the situational cues for the safest course of action appeared to be obvious (with hindsight), but for some inexplicable reason the pilot did not perceive them or they did not trigger the required action. The pilot’s behavior was irrational, out of character.
Are there circumstances where any pilot might act in this manner; – yes, based on my own experience, but fortunately this was not in the air. Anger, fixation, determination (press-on-itis) all contribute to the opportunity for our perception to fail – a realization of the situation but not responding with the appropriate the action. Failed decision making or is this ‘partial incapacitation’? Thus although the Captain may have understood the situation, aided by the First Officers input, he was ‘unable’ to connect with the necessary change in his activity.
What will the report make of this; what, if any recommendations can be made to improve safety?
I doubt if any specific human issue can be identified – something that can be rectified. Accidents consist of an accumulation (coincidences) of many factors and failures, none of which caused the accident, but without any one, it could have been avoided. If we cannot identify cause, then how can it be eliminated? Perhaps it would be better to strengthen the defensive safety barriers that should prevent the ‘coincidences’ forming, but what are they, which ones do we strengthen?
Significant emphasis is placed on the value of cross checking and monitoring, but as indicated in this thread, and in many other accidents, the process is prone to error.
Will a First Officer ever be an effective safety monitor?
I have doubts; the same human weaknesses apply to the pilot monitoring as well as the pilot flying. Even when errors are identified, will any form of intervention be effective. Have there been any successful ‘FO’ takeovers in erroneous situations (ignoring incapacitation)? But there have been instances of failed ‘takeover control’ interventions with serious safety consequences.
Many ‘FO’ discussions relate to ‘taking control’. Is this as taught – are FOs led to believe that this is their primary safety function? From a regulatory standpoint, a newly qualified FO is safe – s/he can fly the aircraft in the event of P1 incapacitation, s/he can monitor and detect errors from ‘the norm’ (SOPs) and participate in the operation of the aircraft, but do they have sufficient experience to intervene (or not) where a more experience Captain is dealing with an unusual situation (to the inexperienced FO), yet due to high workload/fixation fails to communicate intentions / perceptions. When exactly is a FO sufficiently experienced to be an effective monitor and a method of intervention?
Solutions may come from better alerting and initial intervention – getting the pilot flying to change the focus of attention, by providing compelling situation displays with safe courses of action. It is unlikely that these qualities will be found in a new FO, thus we need new technology (previous post) or very experienced FOs – how. One viewpoint is given in Eliminating "cockpit-caused" accidents, – by changing the process of monitoring to use the most experienced pilot as the monitor, this also enables FOs to gain experience quickly.
So the Captain will be a better safety monitor, but not completely error proof. However, there will be operations that require the Captain to fly the aircraft, but with appropriate use of automation the Captain should be able to remain the primary monitor (task allocation) and the FO the very necessary backup for the more difficult operations. There are still weaknesses, but the change offers improvements (less risk of error) over current operations.
Although the FO in this accident appears to have followed the PACE process, his interjections were probably started too late, ultimately too late to takeover even if he could have; – experience, culture, human nature, etc. The ‘error’ – flight path deviation / stabilization, appears to have started much earlier in the approach – during the VNAV segment or even with the FMS setup? Again, there is some similarity with other accidents; the chain of ‘coincidence’ starts well before the ‘accident situation’. The defensive skill here, required by pilots and management, is to ‘see it coming’, whatever ‘it’ is.
Many questions - no answers, only possibilities.
Revisiting the Swiss cheese model of accidents.
There appears to be similarities with the accidents in Bangkok (747) and Burbank (737). In these events, the situational cues for the safest course of action appeared to be obvious (with hindsight), but for some inexplicable reason the pilot did not perceive them or they did not trigger the required action. The pilot’s behavior was irrational, out of character.
Are there circumstances where any pilot might act in this manner; – yes, based on my own experience, but fortunately this was not in the air. Anger, fixation, determination (press-on-itis) all contribute to the opportunity for our perception to fail – a realization of the situation but not responding with the appropriate the action. Failed decision making or is this ‘partial incapacitation’? Thus although the Captain may have understood the situation, aided by the First Officers input, he was ‘unable’ to connect with the necessary change in his activity.
What will the report make of this; what, if any recommendations can be made to improve safety?
I doubt if any specific human issue can be identified – something that can be rectified. Accidents consist of an accumulation (coincidences) of many factors and failures, none of which caused the accident, but without any one, it could have been avoided. If we cannot identify cause, then how can it be eliminated? Perhaps it would be better to strengthen the defensive safety barriers that should prevent the ‘coincidences’ forming, but what are they, which ones do we strengthen?
Significant emphasis is placed on the value of cross checking and monitoring, but as indicated in this thread, and in many other accidents, the process is prone to error.
Will a First Officer ever be an effective safety monitor?
I have doubts; the same human weaknesses apply to the pilot monitoring as well as the pilot flying. Even when errors are identified, will any form of intervention be effective. Have there been any successful ‘FO’ takeovers in erroneous situations (ignoring incapacitation)? But there have been instances of failed ‘takeover control’ interventions with serious safety consequences.
Many ‘FO’ discussions relate to ‘taking control’. Is this as taught – are FOs led to believe that this is their primary safety function? From a regulatory standpoint, a newly qualified FO is safe – s/he can fly the aircraft in the event of P1 incapacitation, s/he can monitor and detect errors from ‘the norm’ (SOPs) and participate in the operation of the aircraft, but do they have sufficient experience to intervene (or not) where a more experience Captain is dealing with an unusual situation (to the inexperienced FO), yet due to high workload/fixation fails to communicate intentions / perceptions. When exactly is a FO sufficiently experienced to be an effective monitor and a method of intervention?
Solutions may come from better alerting and initial intervention – getting the pilot flying to change the focus of attention, by providing compelling situation displays with safe courses of action. It is unlikely that these qualities will be found in a new FO, thus we need new technology (previous post) or very experienced FOs – how. One viewpoint is given in Eliminating "cockpit-caused" accidents, – by changing the process of monitoring to use the most experienced pilot as the monitor, this also enables FOs to gain experience quickly.
So the Captain will be a better safety monitor, but not completely error proof. However, there will be operations that require the Captain to fly the aircraft, but with appropriate use of automation the Captain should be able to remain the primary monitor (task allocation) and the FO the very necessary backup for the more difficult operations. There are still weaknesses, but the change offers improvements (less risk of error) over current operations.
Although the FO in this accident appears to have followed the PACE process, his interjections were probably started too late, ultimately too late to takeover even if he could have; – experience, culture, human nature, etc. The ‘error’ – flight path deviation / stabilization, appears to have started much earlier in the approach – during the VNAV segment or even with the FMS setup? Again, there is some similarity with other accidents; the chain of ‘coincidence’ starts well before the ‘accident situation’. The defensive skill here, required by pilots and management, is to ‘see it coming’, whatever ‘it’ is.
Many questions - no answers, only possibilities.
Revisiting the Swiss cheese model of accidents.