Indonesian B737 runway overrun/crash
Suppose the co-pilot did interfere and did take control of the airplane. What would have happened then?
1. The co-pilot would instantly become a hero as he had just saved many lives and prevented a crash
2. The co-pilot would be fired instantly as he had interfered with the controls. It is so impossible for co-pilots to interfere in South East Asia that true crew coordination never happens.
And that is not really the co-pilot's fault. He is caught up in a deeply rooted system that is flawed, and IMHO he tried everything that he could do to prevent the accident.
Just imagine yourself as an young Indonesian guy, good education, brought up with all the SE Asian values, and suddenly you have to put all your cultural background behind you and interfere in the handling of your direct superior. Who is sitting right next to you!
Surely, he should have taken controls. I am not suggesting anything else. But for him it must have been so much more difficult than it is for western co-pilots.
1. The co-pilot would instantly become a hero as he had just saved many lives and prevented a crash
2. The co-pilot would be fired instantly as he had interfered with the controls. It is so impossible for co-pilots to interfere in South East Asia that true crew coordination never happens.
And that is not really the co-pilot's fault. He is caught up in a deeply rooted system that is flawed, and IMHO he tried everything that he could do to prevent the accident.
Just imagine yourself as an young Indonesian guy, good education, brought up with all the SE Asian values, and suddenly you have to put all your cultural background behind you and interfere in the handling of your direct superior. Who is sitting right next to you!
Surely, he should have taken controls. I am not suggesting anything else. But for him it must have been so much more difficult than it is for western co-pilots.
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http://www.abc.net.au/news/stories/2...22/2066820.htm
Indonesia's police say they may pursue the prosecutions of two pilots criticised in the final report on the crash of a Garuda airliner in Yogyakarta in March.
Indonesia's police say they may pursue the prosecutions of two pilots criticised in the final report on the crash of a Garuda airliner in Yogyakarta in March.
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Just imagine yourself as an young Indonesian guy, good education, brought up with all the SE Asian values, and suddenly you have to put all your cultural background behind you and interfere in the handling of your direct superior. Who is sitting right next to you!
Surely, he should have taken controls. I am not suggesting anything else. But for him it must have been so much more difficult than it is for western co-pilots
Surely, he should have taken controls. I am not suggesting anything else. But for him it must have been so much more difficult than it is for western co-pilots
These culturally challenged operators will always be flying time-bombs and you buy a ticket to ride at your own risk
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DCS99
You asked why? The media release is a very brief and limited version of the report. I don't know how much the report covers but from what I am hearing, Garuda's internal investigation covers a lot. The media release is just a repeat of the preliminary report, with the parts on the f/o not intervening being the only additional part in the media release.
However, something made this otherwise normal person into a cuckoo pilot on that flight. The captain isn't the type to smack the gob of a challenging f/o or cause problems to the junior's career... to the contrary, I spoke to two first officers who is and had flown with the captain and they said he is not the type to ignore the SOP and a guy who listens to the challenges given by his F/Os. Everyone is still wondering why is this guy "out of character" that day. The answer I had from a friend in the NTSC a while back only revealed that "something caused his abnormal behaviour" but was not disclosed in detail.
From second hand stories from those who have talked to the F/O, he mentioned that by the last 1000 feet, the captain was not responsive. He also mentioned that several times the captain said "Oh **** this is going to be a hard one" between 4000 and 1000ft.
The question I keep asking is, why didn't the f/o assume control?
Foxniner & A37575,
He failed to carry out his duty as PM/PNF... simple. Want to blame him or not, that's not for me to decide. I don't know how everyone keeps saying this Asian thing where F/Os are reluctant to take control against the captain when needed. Captains who cannot take criticism or challenges in the interest of safety from his first officer have been "forced to change", or get fired in most cases... and a lot of them ended up working outside Indonesia, which is probably why everyone is still under the general perception that f/os are unassertive in Indonesia.
Over the last 12 months I recall 2 cases in Garuda where the first officer assumed control of the aircraft where the captain was deemed to "contravene SOP and company limitations".
Want to smoke when your f/o doesn't want you to, you chew gum. Want to do that throttle cut off at 50ft? Your F/O will shout "my control", Having "get there-itis" that made you want to "steal minima" claiming you can see the runway when you can't? Your F/O will scream "runway not insight and my control" and initiate the go around. *The above are just from Garuda alone in the past 12 months*
---
Anyways, the Captain has been told by Garuda he won't be flying from the left seat anymore, has been offered a teaching position or leave the company from what I'm told. The F/O, if there are no criminal charges laid against him, then he'll continue to fly but there are doubts from within the company on whether or not he is up for command before his grandchildren's retirement!
PK-KAR
You asked why? The media release is a very brief and limited version of the report. I don't know how much the report covers but from what I am hearing, Garuda's internal investigation covers a lot. The media release is just a repeat of the preliminary report, with the parts on the f/o not intervening being the only additional part in the media release.
However, something made this otherwise normal person into a cuckoo pilot on that flight. The captain isn't the type to smack the gob of a challenging f/o or cause problems to the junior's career... to the contrary, I spoke to two first officers who is and had flown with the captain and they said he is not the type to ignore the SOP and a guy who listens to the challenges given by his F/Os. Everyone is still wondering why is this guy "out of character" that day. The answer I had from a friend in the NTSC a while back only revealed that "something caused his abnormal behaviour" but was not disclosed in detail.
From second hand stories from those who have talked to the F/O, he mentioned that by the last 1000 feet, the captain was not responsive. He also mentioned that several times the captain said "Oh **** this is going to be a hard one" between 4000 and 1000ft.
The question I keep asking is, why didn't the f/o assume control?
Foxniner & A37575,
He failed to carry out his duty as PM/PNF... simple. Want to blame him or not, that's not for me to decide. I don't know how everyone keeps saying this Asian thing where F/Os are reluctant to take control against the captain when needed. Captains who cannot take criticism or challenges in the interest of safety from his first officer have been "forced to change", or get fired in most cases... and a lot of them ended up working outside Indonesia, which is probably why everyone is still under the general perception that f/os are unassertive in Indonesia.
Over the last 12 months I recall 2 cases in Garuda where the first officer assumed control of the aircraft where the captain was deemed to "contravene SOP and company limitations".
Want to smoke when your f/o doesn't want you to, you chew gum. Want to do that throttle cut off at 50ft? Your F/O will shout "my control", Having "get there-itis" that made you want to "steal minima" claiming you can see the runway when you can't? Your F/O will scream "runway not insight and my control" and initiate the go around. *The above are just from Garuda alone in the past 12 months*
---
Anyways, the Captain has been told by Garuda he won't be flying from the left seat anymore, has been offered a teaching position or leave the company from what I'm told. The F/O, if there are no criminal charges laid against him, then he'll continue to fly but there are doubts from within the company on whether or not he is up for command before his grandchildren's retirement!
PK-KAR
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The Australian press today, has indicated that the total blame lies with the aircraft captain.
It made no coments on the actions or otherwise of the First Officer.
It did indicate that a class action against the airline, will be taken by the next of kin, of the Australians lost in the event.
That part of the world seems to be atracting too many cowboys.
Sad time for all
Regards
Col
It made no coments on the actions or otherwise of the First Officer.
It did indicate that a class action against the airline, will be taken by the next of kin, of the Australians lost in the event.
That part of the world seems to be atracting too many cowboys.
Sad time for all
Regards
Col
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The Australian foreign minister, "Alexandra" Downer (a goose, btw) says the Australian Government will lobby for criminal charges to be brought against those responsible for the Garuda crash.
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Names removed. Though I am sure they are in the report
Indonesian police may try to force air safety investigators to provide evidence against a pilot who
ignored fifteen alarms and requests to abort a landing before crashing into Yogyakarta's airport
runway, killing 21 people. The National Transportation Safety Committee investigation into the
March crash has revealed numerous safety breaches by the Garuda pilot, along with serious
deficiencies in training and airport safety procedures. However, committee chairman, Tatang
Kurniadi, said evidence gathered would not be provided to police, provoking anger from relatives of
victims, who included five Australians.
Committee staff would refuse to be interviewed by police, Mr Kurniadi said. He also refused to
release the Boeing 737's "black box" recordings, stating this would breach international aviation
protocol. The chief detective overseeing the investigation said information from the box was key to
the police case. Mr Kurniadi said his staff would refuse any police summonses, and would only testify
in court if charges were laid.
The report stated that pilot descended too steeply at an excessive speed. "During
the approach, the Ground Proximity Warning System alerts (GPWS) and warnings sounded fifteen
times and the co-pilot called for the pilot to go around." The warnings included audible alarms stating
"Too low, terrain" and "Whoop, whoop, pull up". The pilot continued to descend at nearly twice the
maximum safe speed. When it touched the runway the plane bounced and the co-pilot again
screamed to "go around" and abort the landing. The report found rescue and fire vehicles were
unable to reach the crash site and some did not have appropriate fire suppressant.
Mr Kurniadi said the report did not include the terms "human error" or "pilot error" as that would
suggest the pilot was "100% to blame". He said other factors were involved. The aircraft was in good
condition and there was absolutely "no technical fault". The investigation had no authority to
apportion blame, said Indonesia's Transport Minister, Yusmou Syafei Djamal. "The purpose is to
prevent another crash." He said all recommendations would be implemented but could not say when
the runway would be extended to meet international safety standards.
The report found that there had been only one review of Garuda's safety records by airline regulators
in the past nine years. It was critical of Indonesia's Civil Aviation Directorate for failing to ensure
Garuda's safety standards were adequate. Indonesia's police say they are considering their own
investigation which will not have access to the committee's evidence. The co-pilot was also criticised
for not taking control of the aircraft when it was clear the landing conditions were unsafe.
The pilot reportedly did not respond to or disregarded the “very loud” GPWS alerts and warning
phrases that were issued to the cabin in English, but officials have ruled out a language barrier. The
pilot was heard on the cockpit voice recorder saying “wah, nggak beres nih'' (something's not right).
The report accused the pilot of being "fixated or channelised" on landing the plane and the co-pilot of
failing to follow procedures and take over the controls when the pilot ignored warnings. Captain
Pilot and co-pilot, are still grounded. Late yesterday both the
Garuda Pilot's Association and Garuda refused to comment.
The report noted that Captain was singing and engaging in non-essential conversation during
the crucial descent from 10,000 feet to 4000 feet, and that during flight simulator and pilot line testing
last year and in 2005, the 45-year-old had made landing approaches that were too fast. The report
makes recommendations that Garuda clarify its policy on fuel conservation, which has been identified
as a possible reason why pilots choose not to make “go-around'' landings, which burn extra fuel.
The disaster was set in motion sixteen kilometres from the landing zone, when Captain
realised he was significantly higher than he should have been. He reduced altitude sharply, causing the
plane to speed up significantly. However, co-pilot ignored his captain's direction to extend
the landing flaps to their full approach setting. Rather than putting them to 40 degrees, the co-pilot set
the flaps to only five degrees, which, the report notes “is not a landing flap setting'', and called for a
go-around.
With its wing flaps improperly set for landing, the plane hit the runway at 409km/h, 161km/h faster
than the required speed. Shortly afterwards the aircraft's nose wheel structure collapsed and the
plane crashed into an embankment and a paddy field, where fuel from its ruptured tanks quickly
caught fire, destroying the fuselage completely. "The pilot was probably emotionally aroused because
his conscious awareness moved from the relaxed mode "singing" to the heightened stressfulness of the
desire to reach the runway by making an excessively steep and fast, unstabilised approach," the
report said.
Indonesian police may try to force air safety investigators to provide evidence against a pilot who
ignored fifteen alarms and requests to abort a landing before crashing into Yogyakarta's airport
runway, killing 21 people. The National Transportation Safety Committee investigation into the
March crash has revealed numerous safety breaches by the Garuda pilot, along with serious
deficiencies in training and airport safety procedures. However, committee chairman, Tatang
Kurniadi, said evidence gathered would not be provided to police, provoking anger from relatives of
victims, who included five Australians.
Committee staff would refuse to be interviewed by police, Mr Kurniadi said. He also refused to
release the Boeing 737's "black box" recordings, stating this would breach international aviation
protocol. The chief detective overseeing the investigation said information from the box was key to
the police case. Mr Kurniadi said his staff would refuse any police summonses, and would only testify
in court if charges were laid.
The report stated that pilot descended too steeply at an excessive speed. "During
the approach, the Ground Proximity Warning System alerts (GPWS) and warnings sounded fifteen
times and the co-pilot called for the pilot to go around." The warnings included audible alarms stating
"Too low, terrain" and "Whoop, whoop, pull up". The pilot continued to descend at nearly twice the
maximum safe speed. When it touched the runway the plane bounced and the co-pilot again
screamed to "go around" and abort the landing. The report found rescue and fire vehicles were
unable to reach the crash site and some did not have appropriate fire suppressant.
Mr Kurniadi said the report did not include the terms "human error" or "pilot error" as that would
suggest the pilot was "100% to blame". He said other factors were involved. The aircraft was in good
condition and there was absolutely "no technical fault". The investigation had no authority to
apportion blame, said Indonesia's Transport Minister, Yusmou Syafei Djamal. "The purpose is to
prevent another crash." He said all recommendations would be implemented but could not say when
the runway would be extended to meet international safety standards.
The report found that there had been only one review of Garuda's safety records by airline regulators
in the past nine years. It was critical of Indonesia's Civil Aviation Directorate for failing to ensure
Garuda's safety standards were adequate. Indonesia's police say they are considering their own
investigation which will not have access to the committee's evidence. The co-pilot was also criticised
for not taking control of the aircraft when it was clear the landing conditions were unsafe.
The pilot reportedly did not respond to or disregarded the “very loud” GPWS alerts and warning
phrases that were issued to the cabin in English, but officials have ruled out a language barrier. The
pilot was heard on the cockpit voice recorder saying “wah, nggak beres nih'' (something's not right).
The report accused the pilot of being "fixated or channelised" on landing the plane and the co-pilot of
failing to follow procedures and take over the controls when the pilot ignored warnings. Captain
Pilot and co-pilot, are still grounded. Late yesterday both the
Garuda Pilot's Association and Garuda refused to comment.
The report noted that Captain was singing and engaging in non-essential conversation during
the crucial descent from 10,000 feet to 4000 feet, and that during flight simulator and pilot line testing
last year and in 2005, the 45-year-old had made landing approaches that were too fast. The report
makes recommendations that Garuda clarify its policy on fuel conservation, which has been identified
as a possible reason why pilots choose not to make “go-around'' landings, which burn extra fuel.
The disaster was set in motion sixteen kilometres from the landing zone, when Captain
realised he was significantly higher than he should have been. He reduced altitude sharply, causing the
plane to speed up significantly. However, co-pilot ignored his captain's direction to extend
the landing flaps to their full approach setting. Rather than putting them to 40 degrees, the co-pilot set
the flaps to only five degrees, which, the report notes “is not a landing flap setting'', and called for a
go-around.
With its wing flaps improperly set for landing, the plane hit the runway at 409km/h, 161km/h faster
than the required speed. Shortly afterwards the aircraft's nose wheel structure collapsed and the
plane crashed into an embankment and a paddy field, where fuel from its ruptured tanks quickly
caught fire, destroying the fuselage completely. "The pilot was probably emotionally aroused because
his conscious awareness moved from the relaxed mode "singing" to the heightened stressfulness of the
desire to reach the runway by making an excessively steep and fast, unstabilised approach," the
report said.
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I'm glad to say the final report is released for public viewing. I received a call today on this describing the long debate from within the Department of Communications, in particular the NTSC, on whether or not they should release the final report.
In the end, the good guys won, and the report was released to the public. This "admission of our weaknesses" is just another stepping stone forward into changing the overall safety mentality of the country's aviation. The NTSC was under enormous pressure from both sides of the debate and the decision to release came from the head of the NTSC, with what I am told the reason being, "it's about time we educate everyone here about what is safety."
I'm sure there were compromises made in the report, which probably resulted in the "broad and general" nature of the findings. Despite the lack of details which I expected, at least it sounds like the report is hitting the right issues.
On the issue of the releasing the evidence to the police, again, the NTSC is between a rock and a hard place. The police investigation in the beginning was not supposed to investigate who was criminally liable, but to investigate the possibility terrorism being a factor because of the names in the passenger manifest. Releasing the evidence would also lead to court cases being filed to obtain evidence from other accidents. While I personally doubt there was any mal-intentions to those certain people want to bring to the dock, I find it funny that in this case where the accident revealed systemic deficiencies instead of neglicence with criminal intent, people are pushing for the evidence where other accidents where there are indications of a cover-up to the extent of criminal liability, isn't being pushed for evidence disclosure.
Releasing the evidence in this investigation I fear would lead to terminal criminalization of accidents which would hinder the essential ingredients of improvements in safety, that is honesty.
No mention on his "out of the job matters" which have increasingly affected him in recent months according to some people who know him...
Anyways, perhaps the "pilot shortage" has something to do with the action of the first officer (as a result of training deficiencies perhaps?)
PK-KAR
In the end, the good guys won, and the report was released to the public. This "admission of our weaknesses" is just another stepping stone forward into changing the overall safety mentality of the country's aviation. The NTSC was under enormous pressure from both sides of the debate and the decision to release came from the head of the NTSC, with what I am told the reason being, "it's about time we educate everyone here about what is safety."
I'm sure there were compromises made in the report, which probably resulted in the "broad and general" nature of the findings. Despite the lack of details which I expected, at least it sounds like the report is hitting the right issues.
On the issue of the releasing the evidence to the police, again, the NTSC is between a rock and a hard place. The police investigation in the beginning was not supposed to investigate who was criminally liable, but to investigate the possibility terrorism being a factor because of the names in the passenger manifest. Releasing the evidence would also lead to court cases being filed to obtain evidence from other accidents. While I personally doubt there was any mal-intentions to those certain people want to bring to the dock, I find it funny that in this case where the accident revealed systemic deficiencies instead of neglicence with criminal intent, people are pushing for the evidence where other accidents where there are indications of a cover-up to the extent of criminal liability, isn't being pushed for evidence disclosure.
Releasing the evidence in this investigation I fear would lead to terminal criminalization of accidents which would hinder the essential ingredients of improvements in safety, that is honesty.
"The pilot was probably emotionally aroused because his conscious awareness moved from the relaxed mode "singing" to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilised approach," the report said.
Anyways, perhaps the "pilot shortage" has something to do with the action of the first officer (as a result of training deficiencies perhaps?)
PK-KAR
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PK please don’t confuse the criminalisation of air accidents by the misguided prosecution of individuals with honouring your ICAO treaty obligations to make investigation reports public. It is a condition in the treaty that the report be published. OK, so ICAO has never done anything about anybody who violates this clause, but that doesn’t we should prostrate ourselves in gratitude before any state that does publish, and it is kind of depressing (don't weigh in everybody with "This is Asia" bla bla) to read about "long debates" about whether to do the right and legal thing or not.
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Final report here http://www.dephub.go.id/knkt/ntsc_aviation/aaic.htm
Shame that both John Howard and Kevin Rudd are playing to their political audience in calling for the "full weight of the law be brought to bear in the prosecution of the pilots."
Note in the report that both crew refused to answer questions as to their pre duty activities.
Shame that both John Howard and Kevin Rudd are playing to their political audience in calling for the "full weight of the law be brought to bear in the prosecution of the pilots."
No mention on his "out of the job matters" which have increasingly affected him in recent months according to some people who know him
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Frangible,
Sorry if I sounded confused, but I mixed in my rants as there have been people here who are openly criticizing the NTSC in carrying out its duties by not apportioning blame in the investigation. As to whether or not it should be publish, of course it should but as we see, reports were not published over the last few years due to political and commercial pressures by certain factions. I am not saying "we're great now because we're publishing it", I'm saying that "I'm glad common sense has now prevailed," and we're getting back on the right track again. It's been a very frustrating few recent year on this issue...
Brian,
Dang it! It's been nearly impossible to download that report here. I've been trying to download it since yesterday and only today that I'm having some luck in grabbing the gaps in their bandwidth! 
Sorry if I sounded confused, but I mixed in my rants as there have been people here who are openly criticizing the NTSC in carrying out its duties by not apportioning blame in the investigation. As to whether or not it should be publish, of course it should but as we see, reports were not published over the last few years due to political and commercial pressures by certain factions. I am not saying "we're great now because we're publishing it", I'm saying that "I'm glad common sense has now prevailed," and we're getting back on the right track again. It's been a very frustrating few recent year on this issue...
Brian,
Note in the report that both crew refused to answer questions as to their pre duty activities.
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Indonesian B737 runway overrun/crash
OK, here is the direct link;
http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final%20report%20PK-GZC%20Release.pdf
Good luck with your downloads!
http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final%20report%20PK-GZC%20Release.pdf
Good luck with your downloads!
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I'm not a pilot. So some naive questions.
If you are "significantly too high 16km out" could you recover the correct approach height and speed at all? Or with 40 deg of flaps set?
Might you not notice that your final approach was 98 knots too fast?
Are there any normal circumstances in which you would ignore a GWPS and not automatically go round on the basis that the time to find out what is wrong is after the aircraft is in a stable climb?
Finally, how does the f/o assume control? In the last resort is it the stronger pilot?
Now to get flamed. Rainboe to stand by. If I were a captain and the f/o wanted control, I would reflect that if I'm wrong I'm dead, if he's wrong he's starting a new career tomorrow. Unless, of course, I thought the f/o was going to kill us.
Over to you.
If you are "significantly too high 16km out" could you recover the correct approach height and speed at all? Or with 40 deg of flaps set?
Might you not notice that your final approach was 98 knots too fast?
Are there any normal circumstances in which you would ignore a GWPS and not automatically go round on the basis that the time to find out what is wrong is after the aircraft is in a stable climb?
Finally, how does the f/o assume control? In the last resort is it the stronger pilot?
Now to get flamed. Rainboe to stand by. If I were a captain and the f/o wanted control, I would reflect that if I'm wrong I'm dead, if he's wrong he's starting a new career tomorrow. Unless, of course, I thought the f/o was going to kill us.
Over to you.
Per Ardua ad Astraeus
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By no means naive:
1) Probably not - it depends on how 'significant' 'significantly' is. Flap 40 has a lowish maximum speed limit so you cannot use it until you have slowed up.
From the report "At 23:55:33, when the aircraft was 10.1 miles from the runway, it was 1,427 feet above the initial fix of 2,500 feet published in the approach chart, and the airspeed was 283 knots" Absolutely NO WAY!
2) no
3) no
4) by saying, after verbal warnings, 'I have control'. If no reaction, shout; if still no reaction it will be a physical struggle. Last resort a physical attack - but he/she had better be very sure
I believe AB has an option to switch control sticks.
5) You are probably right - stand by
1) Probably not - it depends on how 'significant' 'significantly' is. Flap 40 has a lowish maximum speed limit so you cannot use it until you have slowed up.
From the report "At 23:55:33, when the aircraft was 10.1 miles from the runway, it was 1,427 feet above the initial fix of 2,500 feet published in the approach chart, and the airspeed was 283 knots" Absolutely NO WAY!
2) no
3) no
4) by saying, after verbal warnings, 'I have control'. If no reaction, shout; if still no reaction it will be a physical struggle. Last resort a physical attack - but he/she had better be very sure
I believe AB has an option to switch control sticks.5) You are probably right - stand by
Warning Toxic!
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Disgusted of Tunbridge
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2G1P- sensible questions ably answered. A shocking and shameful sequence of events that brings the industry into disrepute. Flying standards and training in some parts of the world are beyond comprehension. When you throw into the mix some rather questionable attitudes and methods, then simple CRM courses are nowhere near enough to change the way things are done.
I can't help thinking how insurance companies can keep providing insurance for certain regions of the world without severe changes in the way things are done, but then it's not my problem. It almost seems insurmountable sometimes.
I can't help thinking how insurance companies can keep providing insurance for certain regions of the world without severe changes in the way things are done, but then it's not my problem. It almost seems insurmountable sometimes.
This accident involved HF, but the comprehensive report, as with many previous ones, fails to provide specific information enabling the industry to avoid similar situations.
The HF annex describes fixation / attention channeling on which finding 11 is based; however, there are no recommendations as to how to avoid such fixation or for overcoming the non-intervention by the NFP/PM (finding 8).
The significant safety issue is that in different ways both humans failed (encountered error) at the same time, yet the industry depends on the duality and ‘defense in depth’ afforded by two pilots.
Any PF can suffer fixation and associated ‘failure to hear’ (perceive information); thus providing the NFP/PM has detected the error, the problem is how to break into the PF’s mental attention. As the audio channel is not available, it is widely assumed that physical intervention via the controls will follow, but in many accidents this has not occurred for a wide variety of reasons.
Do any operators consider a tap on the glareshield or even ‘a tap on the hand/shoulder’ to break the fixation? These actions might be easier for the NFP to undertake in situations involving low assertiveness or cultural bias, and avoid many of the problems of last-resort physical overpowering with the associated hazard of unstable control. Also, these actions can take place earlier in the TEM/monitoring process, possibly as a second step in error alerting where attention appears to be incorrectly focused.
As a speculative thought, the PF might have been distracted by a DME range / altitude mismatch. Referring to the vertical profile and longer range scale on P81 (Fig 8), the initial flight path (> 4 DME JOG) appears sufficient to achieve the required altitude profile at JOG, i.e. the approach appears to be progressing satisfactorily although fast. However, before JOG the descent rate was reduced such that the flight path now intercepts the JOG altitude but at IJOG – the ILS DME.
The FDR analysis used ‘DME LEFT’, but there is no report of when the ILS/DME was tuned or what was indicated on the right side. If the DME was retuned to the ILS just before JOG then the PF may have suffered a mental map slip in his approach descent planning, resulting in a confused situation and an attention sapping problem – why has the situation changed. These types of errors can be avoided by briefing, good crew co-ordination, crew calls associated with change of frequency, and a thorough instrument scan – one where information is perceived and related to the situation, i.e not just ‘seen’.
Whether the speculation is relevant or not, it points to aspects in this and similar accidents that indicate that the causal problems often originate much earlier in the approach than indicated where investigations tend to focus on the what of ‘stopping’ the aircraft and not the why it got there - human activities.
It is good to see positive aspects such as the review of fuel policy – even if the crew believed that they were not affected, the subconscious has a powerful influence.
The recommendation for operators to consider non standard RESA is also positive, but what will operators chose to do; reduce the landing distance available, wet vs dry performance, new procedures, etc? Any thoughts?
The HF annex describes fixation / attention channeling on which finding 11 is based; however, there are no recommendations as to how to avoid such fixation or for overcoming the non-intervention by the NFP/PM (finding 8).
The significant safety issue is that in different ways both humans failed (encountered error) at the same time, yet the industry depends on the duality and ‘defense in depth’ afforded by two pilots.
Any PF can suffer fixation and associated ‘failure to hear’ (perceive information); thus providing the NFP/PM has detected the error, the problem is how to break into the PF’s mental attention. As the audio channel is not available, it is widely assumed that physical intervention via the controls will follow, but in many accidents this has not occurred for a wide variety of reasons.
Do any operators consider a tap on the glareshield or even ‘a tap on the hand/shoulder’ to break the fixation? These actions might be easier for the NFP to undertake in situations involving low assertiveness or cultural bias, and avoid many of the problems of last-resort physical overpowering with the associated hazard of unstable control. Also, these actions can take place earlier in the TEM/monitoring process, possibly as a second step in error alerting where attention appears to be incorrectly focused.
As a speculative thought, the PF might have been distracted by a DME range / altitude mismatch. Referring to the vertical profile and longer range scale on P81 (Fig 8), the initial flight path (> 4 DME JOG) appears sufficient to achieve the required altitude profile at JOG, i.e. the approach appears to be progressing satisfactorily although fast. However, before JOG the descent rate was reduced such that the flight path now intercepts the JOG altitude but at IJOG – the ILS DME.
The FDR analysis used ‘DME LEFT’, but there is no report of when the ILS/DME was tuned or what was indicated on the right side. If the DME was retuned to the ILS just before JOG then the PF may have suffered a mental map slip in his approach descent planning, resulting in a confused situation and an attention sapping problem – why has the situation changed. These types of errors can be avoided by briefing, good crew co-ordination, crew calls associated with change of frequency, and a thorough instrument scan – one where information is perceived and related to the situation, i.e not just ‘seen’.
Whether the speculation is relevant or not, it points to aspects in this and similar accidents that indicate that the causal problems often originate much earlier in the approach than indicated where investigations tend to focus on the what of ‘stopping’ the aircraft and not the why it got there - human activities.
It is good to see positive aspects such as the review of fuel policy – even if the crew believed that they were not affected, the subconscious has a powerful influence.
The recommendation for operators to consider non standard RESA is also positive, but what will operators chose to do; reduce the landing distance available, wet vs dry performance, new procedures, etc? Any thoughts?
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Fatigue also a factor?
CRASH PILOT SUFFERED MARITAL STRIFE
the pilot responsible for the Garuda air disaster in March that killed 21 people,
including five Australians, may have been distracted by fights with his wife and too little sleep the night
before the crash, fellow pilots have claimed. Indonesian police have confirmed that an accident
report, which identified Captain's poor decision-making as a key cause of the crash,
contained enough material to move to the next stage of a criminal prosecution. Garuda pilots
association president Stephanus Geraldus said yesterday problems at home helped explain why the
respected Captain, 45, attempted the high-speed landing on March 7.
Geraldus said conflict between Captain and his wife, former air hostess, was
“common knowledge''. The claim was backed up by aviation industry analyst Dudi Sudibyo, who
expressed disappointment that the report failed to delve into the pilot's mental state. Captain
and his co-pilot, reported at 4.30am for the scheduled 6am Jakarta-Yogyakarta
flight, the crash report said. “What I want to know now is: why he didn't report that lack of sleep and
ask to be shifted to the next flight, or maybe he felt extremely confident he could fly - overconfident,''
Sudibyo said.
National police spokesman Sisno Adiwinoto said the pilots had gone to ground since the crash and
were likely to face manslaughter charges once expert witnesses were called to complete the criminal
case. The report said there was no evidence that the pilots were unfit to fly, but that “they did not
provide the investigation with information about (their) activities during the 72 hours prior to
commencing duty''. Police in Yogyakarta, who have jurisdiction for the criminal prosecution, said
yesterday they were awaiting a copy of the crash report so they could proceed.
“We're looking to prosecute under criminal negligence causing death and serious injury,'' national
police spokesman Sisno Adiwinoto said. “We need witnesses who can prove there was negligence,
and since this was an aviation matter, that could be someone from the national safety transportation
committee, or it could also be a medical doctor because of the deaths and injuries. “We have been
proceeding with this investigation all along, but we needed enough preliminary evidence, which we
now do have, with the report that says, yes, there was human negligence.'' He also said it was
possible that Garuda could be prosecuted for failing to properly train pilots. The report criticised
Indonesia's Director-General of Civil Aviation for neglecting to fix Garuda's training failings. (Source:
The Australian)
CRASH PILOT SUFFERED MARITAL STRIFE
the pilot responsible for the Garuda air disaster in March that killed 21 people,
including five Australians, may have been distracted by fights with his wife and too little sleep the night
before the crash, fellow pilots have claimed. Indonesian police have confirmed that an accident
report, which identified Captain's poor decision-making as a key cause of the crash,
contained enough material to move to the next stage of a criminal prosecution. Garuda pilots
association president Stephanus Geraldus said yesterday problems at home helped explain why the
respected Captain, 45, attempted the high-speed landing on March 7.
Geraldus said conflict between Captain and his wife, former air hostess, was
“common knowledge''. The claim was backed up by aviation industry analyst Dudi Sudibyo, who
expressed disappointment that the report failed to delve into the pilot's mental state. Captain
and his co-pilot, reported at 4.30am for the scheduled 6am Jakarta-Yogyakarta
flight, the crash report said. “What I want to know now is: why he didn't report that lack of sleep and
ask to be shifted to the next flight, or maybe he felt extremely confident he could fly - overconfident,''
Sudibyo said.
National police spokesman Sisno Adiwinoto said the pilots had gone to ground since the crash and
were likely to face manslaughter charges once expert witnesses were called to complete the criminal
case. The report said there was no evidence that the pilots were unfit to fly, but that “they did not
provide the investigation with information about (their) activities during the 72 hours prior to
commencing duty''. Police in Yogyakarta, who have jurisdiction for the criminal prosecution, said
yesterday they were awaiting a copy of the crash report so they could proceed.
“We're looking to prosecute under criminal negligence causing death and serious injury,'' national
police spokesman Sisno Adiwinoto said. “We need witnesses who can prove there was negligence,
and since this was an aviation matter, that could be someone from the national safety transportation
committee, or it could also be a medical doctor because of the deaths and injuries. “We have been
proceeding with this investigation all along, but we needed enough preliminary evidence, which we
now do have, with the report that says, yes, there was human negligence.'' He also said it was
possible that Garuda could be prosecuted for failing to properly train pilots. The report criticised
Indonesia's Director-General of Civil Aviation for neglecting to fix Garuda's training failings. (Source:
The Australian)
Join Date: Nov 2001
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Finally the cat's out of the bag!
Frankly, I don't know why the NTSC omitted this, perhaps they preferred to go and identify more systemic deficiencies.
Frankly, I don't know why the NTSC omitted this, perhaps they preferred to go and identify more systemic deficiencies.