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Indonesian B737 runway overrun/crash

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Old 12th Mar 2007, 05:05
  #161 (permalink)  
 
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nojwod,
the scenario you describe is quite (possibly even very) plausible. But if what you describe turned out to be correct - the crew would be 100% responsible for failure to conduct/monitor the approach correctly - both from an AFM standpoint and, I think fair to assume, from the point of view of company SOP's (I'd imagine Garuda SOP's cover the issue comprehensively like everyone elses - but I don't know what they actually are).
Although the Italian witness mentions flaps - it is stated in a manner which isn't really definitive. What he does state clearly concerns the spoilers. If this is true - that alone would be another breech of AFM limitations - no spoiler deployment below 500'AGL when visual (at least that's my information - others may differ slightly in their AFM and SOP's)

As far as INADVERTANTLY leaving the spoiler deployed - that's why it's a damned good idea to keep your hand on the lever when it's out - and not take it off 'till it's stowed. This has figured in disasters before - performance analysis indicates it was a probable factor in the CFIT at Cali, Colombia, during the attempted escape manoeuvre. I'd have a genuine difficulty in seeing that happening by accident - all the way down - and with neither crew member spotting it. Even if only from the higher than normal n1's and the change in pitch needed to maintain the g/s.
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PK-KAR,
- just thinking about Flap 30 again - if spoilers also deployed (not recommended beyond flap 15 from Mr. B' - due severe vibration and possible damage) I imagine there would be buffeting which would border on the severe. I don't think anyone reported anything which could be explained as buffeting - maybe pushes things away from having landing flaps selected again?

ATC transmissions don't indicate anything really - except to educate me about the "check gear down and locked" advisory - I've honestly never heard of that being done before - but a good prudent idea given the military training

I find it strange (obviously not suspecting malice or anything else) that Captain Stephanus gave some information about the crew's conversation with him - but never actually mentioned what the minor technical problem was.
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Old 12th Mar 2007, 05:07
  #162 (permalink)  
 
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Tightcircuit,
It is possible, I am not dismissing your claims at all... especially given the surrounding factors you mentioned. I have been in similar situations, though relieved they took their time after what it seems to be "omissions of certain aspects of pre-airborne tasks", and we sped up in the air instead.

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Old 12th Mar 2007, 05:11
  #163 (permalink)  
 
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but never actually mentioned what the minor technical problem was.
From a separate source, I'm awaiting confirmation regarding the brakes being changed from the day before. Plus, the #1 reverser was locked before the flight, and the crew were aware of it. The reason was due to delayed deployment (as far as I am told).

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Old 12th Mar 2007, 17:54
  #164 (permalink)  
 
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Amos2, I think that’s just because the original poster was mirroring the first media reports.- Had it been here – the first report I heard in this neck of the woods said “five feared dead”. So understandable, if indeed inaccurate now.

brakes being changed from the day before……........#1 reverser was locked before the flight
Getting into the realms of speculation again – so more in terms of thinking aloud – from the second contact point you indicated, if still a good bit beyond Vref(even for Flap 30) breaking to a stop and staying on the runway becoming doubtful – I think (885m - time to start manual braking, even if autobrake selected, time to get to full manual application, possible modulating if directional control a problem, POSSIBLY your crewmate thinking of GA and applying thrust again(even for a brief time)). I think you mentioned something like ‘track marks’ earlier – if I’m not misunderstanding – even with max. manual braking that, could indicate anti-skid problem – I know I don’t have enough facts and this is really reaching at this stage.

Reverser locked (not unusual)– well we know is not a requirement from regulatory and AFM standpoint. For DRY runway – should have no bearing on decision making of actual performance BEFORE the landing – as for any effect on what seems to have happened on the runway if both reversers were available – we’re heading into the realms of detailed performance analysis of FDR data. If your theory is correct – one pilot trying to GA and the other trying to stop, if reverse thrust had been available and selected by one – that would/should have been the end of trying for GA. I think the suggestion of confusion arising in the cockpit is pretty compelling over a GA or not decision.

In thinking about chain of events - plenty of incidents in the past with initial minor mistake leading to further mistakes/wrong decisions, all the time - the potential consequence of each step becoming worse. Like a cascade of disaster - some pilots have become 'trapped' in the sequence - inspite of their training and 'our' retrospectively applied common-sense.

Everything is pretty much “up in the air” still (no pun intended). Still a bit hopeful, like before – but I think that it is becoming more desperate as time goes by.




To get away from the specifics of GA200 momentarily, I do have a ‘statistical’ curiosity/question for anyone experienced in the professional field of Indonesian aviation. If for a moment we were to assume that ALL operators were performing in the way they should/how we would like them to, with total fleet age/maintenance profile that would match anywhere else. In terms of amount of traffic, the myriad of airfields/available facilities served across so many islands, frequently challenging terrain in many of those places, and ‘rainy’ season tropical weather/runway length generally available. It SEEMS to me that Indonesia could expect to have a higher incident rate than another tropical country, in any fair comparison anyway. Just wondering if any Indonesians, or expats with experience working in Indonesia, would agree or disagree?
I’m asking because I want to ‘test the water’ wrt the general situation – without reference to the frequently misleading/sometimes condescending media reports. To date, my limited personal experience base in Indonesia (non-professional) starts and ends in Java, but I do have a reasonable understanding at the ‘socio-political’ level and the background as relates to corruption.

Wrt the tone of previous threads related to Indonesia – it seems impossible to improve aviation/general transport safety in isolation – in terms of corruption generally. Unless maybe you think in terms of appointing an “aviation imperator” with the specific purpose of getting things sorted out (similar to Russia/Aeroflot years ago) – but then that requires political will/cooperation – (Adamair!?!)
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Old 12th Mar 2007, 18:10
  #165 (permalink)  
 
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A lot of posters have been critical of the aircrew but until we know what technical malfunctions occurred during the flight, and there may have been many, certain members of this forum should not be so quick to criticise the aircrew in my opinion.

I'm fairly certain that investigators will find multiple causes for this accident, and the extent to which the aircrew affected the outcome is currently unknown. As a forum, shouldn't we support the aircrew rather than criticise them and speculate about what they might have done wrong? I expect that those who are being critical would expect no less than this of their fellow professionals if they were in the unfortunate position that this Garuda crew finds themselves in.

Porrohman.
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Old 12th Mar 2007, 18:59
  #166 (permalink)  
 
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Theamrad,
The brake change can't be confirmed yet.
The #1 Reversers inoped is more or less believable, but shouldn't affect the landing performance as you said... single reverser didn't cause the accident, but is a contributor to the effects of the accident thanks to reduced deceleration ability and controllability issue if one "lost the plot"...

I think you mentioned something like ‘track marks’ earlier – if I’m not misunderstanding – even with max. manual braking that, could indicate anti-skid problem – I know I don’t have enough facts and this is really reaching at this stage.
Would max man brakes with antiskid protection result in some track marks?

If your theory is correct – one pilot trying to GA and the other trying to stop, if reverse thrust had been available and selected by one – that would/should have been the end of trying for GA. I think the suggestion of confusion arising in the cockpit is pretty compelling over a GA or not decision.
As likely/unlikely as it is, I must advise caution on this one at this stage of the investigation. As you said rightly, a small mishap can lead to a disaster if one does not act/react correctly, but I'm extremely curious on what the pilots will say on what happened and their reasonings for their actions before I go anywhere near judging them.

As to improving the situation, let's just say that improvements in a lot of aspects happened between 2000 and 2004 (I'm not talking about the rate of mishaps but the general atmosphere of the industry in terms of safety mentality), but, since then, it appears to have gone downhill extremely fast for some reason.

PK-KAR

Last edited by PK-KAR; 12th Mar 2007 at 19:15.
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Old 12th Mar 2007, 22:38
  #167 (permalink)  
 
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Porrohman – I’ve no wish to impune your right to an opinion, but I think in fairness I would have to say that I can’t understand your criticism concerning the speculation of some posters here (just because the thinking of some, rightly or wrongly, on available information, leads them to think the crew possibly or probably caused this)– when you yourself have been speculating as to cause. Why should speculation about possible crew action not be allowed – but speculation about possible tech’ problems be ok? Personally I try my best to look at things from a cause standpoint (whether crew, weather, tech or otherwise) as opposed to blame. I don’t think there’s anything wrong with reasonable/informed speculation based on our personal knowledge base and the best available information – it’s the stuff based on complete supposition, those with no background/knowledge of aviation matters and/or ‘information’ from the wildest of some of the media tirades that I personally find annoying.
I expect that those who are being critical would expect no less than this of their fellow professionals if they were in the unfortunate position that this Garuda crew finds themselves in
Like it or not – I think that’s just the ‘way things are’ – I’m pretty sure almost all of us know that if someone here screwed up badly on any given day – there’d be a thread started here about it before we could even catch our breath. Then again – reasoned discussion versus unfounded waffle makes a big difference! I don’t know about you – but I myself don’t have a problem about knowing, or others knowing, I’m not infallible. The day I feel otherwise – I think, is the day that others are in danger. I hope my ego doesn’t dictate how well or not I should react to reasonable peer comment, whether criticism or advice. If I screwed up – I wouldn’t expect my peers to defend me blindly – I would like if they applied reason/knowledge/pertinent facts in their discussions though. I can only speak for myself on this – whether or not they were to blame in the final analysis has no bearing on the level of how unfortunate I think their predicament is now.
Peace.

-------------------------
if one "lost the plot"...
Yep – that could make an already bad situation a whole lot worse.

Would max man brakes with antiskid protection result in some track marks?

Probably better for the techies at this stage – but to hazard an OPINION with carefully chosen words. I THINK it probably would. But I would argue, that it should be easy (for investigators) to tell the difference between max brake a/skid operative with possible pattern closely spaced due modulation at a/skid normal working freq, and what would result from a/skid inop – with more sustained lock-up, higher temp at contact point, etc (even if pilot perceives skid and tries to modulate manually - pattern likely to vary over interval in the order of seconds)
- all just my opinion of course.
if one does not act/react correctly
I’ve seen enough reports with detailed ‘human factors’ input to realise some were caused initially by relatively simple mistakes – which any pilot could have made. I don’t wish to be judgmental either: The incidents I know of where things went along the lines of this type of scenario – became so dynamic – that I don’t think any reasonably minded person would expect the ordinary notions of CRM to provide any relief to the crew. One incident occurred here as a result of a land/GA conflict in marginal weather (wind/gust/shear) – fortunately the only consequences were nose gear damage. But the events in the cockpit became very dynamic and understandably confusing to both crew members. All this without prejudice to this accident – we were still dealing with a speculated scenario and, as you say, many more facts are as yet unknown.
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Old 12th Mar 2007, 22:55
  #168 (permalink)  
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theamrad, would you be living in Cork by any chance, near the Blarney stone?
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Old 12th Mar 2007, 23:32
  #169 (permalink)  
 
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Theamrad,

I agree with your comments. I've no problem with criticism of the aircrew where evidence indicates that it's warranted, and you make a fair point that I was speculating (in a post which is now deleted) about faults in the machine where the evidence to support such suggestions was questionable. I'll try to be more careful with my posts in future.

Porrohman.
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Old 13th Mar 2007, 02:50
  #170 (permalink)  
 
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ATSB Gets "Nothing Useful" out of CVR.

According to the Australian today (sorry no link) the Australian Transport Safety Board, which is assisting Indonesian authorities, has gotten nothing useful (whatever that means) out of the CVR and the FDR only has records of 22 or so parameters out of a total of 200. The boxes have apparently been forwarded to Boeing for further analysis.

It appears that the speculation may continue for a while yet.
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Old 13th Mar 2007, 03:06
  #171 (permalink)  
 
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This article - http://www.theaustralian.news.com.au...-23349,00.html claims that the ATSB have already sent a reasonable amount of data from the FDR to Indonesia and that they were having problems with the CVR reconstruction.
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Old 13th Mar 2007, 03:31
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theamrad, would you be living in Cork by any chance, near the Blarney stone?
No dude - that's quite a bit away from me - I'm at the civilised end of things - just kidding..........no really I am! I like Cork a lot - and I've met many fine people there over the years!

Porrohman - sorry if it seemed a bit harsh - i meant it in the tone of discussion, not criticism. At this stage, I'm finding it hard myself not to wander of what I think is reasonable speculation and into what is pushing into the realms of fiction writing! I have to keep reminding myself to stick to what's known so far (which is very little). ''nuf said'

records of 22 or so parameters out of a total of 200
Not sure what they mean 'out of 200' - 22 parameters sound about right for what would have been fitted originally, and mandated at that time? I remember one incident(B737) in the US not too long before the time this aircraft was manufactured where only 5 parameters were recorded - any type of mandate for improvement only came out in US sometime after that incident (I think!).
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Old 13th Mar 2007, 06:18
  #173 (permalink)  
 
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Boeing or Honeywell?

Hi forum-ites,
I've been reading this forum since the Adam Air crash since January and it's a valuable source of knowledge. I'm a research consultant, based in Indonesia, and I'm a bit perplexed by something. The local media in Indonesia has repeatedly stated over the last 24 hours that the CVR is "being sent to Boeing for analysis." Everything I've read from wire services or other international reports say it's going to Honeywell -- the manufacturer.

The significance of this was brought to light in an Indonesian paper today, wherein a 'local aviation observer' makes accusations of foul play on the part of Australian and US investigators and claims that Boeing (presumably with the CVR now in its possession) will destroy evidence of "problems that may emerge with the Boeing 737..."

Another poster above also mentioned Boeing. BTW, Honeywell Aerospace is in Redmond, WA next door to Microsoft and Boeing is in Seattle, about 10 miles away.
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Old 13th Mar 2007, 07:08
  #174 (permalink)  
 
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Riccardo,
Which paper? I'd be interested to give my word to the paper! *evil grin*

PK-KAR
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Old 13th Mar 2007, 07:22
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The Point newspaper

Hi Pk-Kar,

It was the lead, front-page story in today's (Tuesday March 13) English-language daily, THE POINT. They don't have an active website yet, but I've put more of the article quotes on my blog/forum here: http://grsb.jakchat.com

Last edited by RiccardoGRSB; 13th Mar 2007 at 07:24. Reason: url correction
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Old 13th Mar 2007, 07:46
  #176 (permalink)  
 
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Riccardo,
Knowing Dudi Sudibyo, the "observer" quoted, I find it EXTREMELY HARD TO BELIEVE that he said what he said. He is an editor at the local aviation magazine, so we'll know if he was misquoted or he did actually say those things if Angkasa magazine starts claiming those too!

After reading this:
What the Aussies did find is that there was no windshear, no downdraft and nothing out of the ordinary in terms of weather. However, that stands in stark contrast to what the Garuda pilot's union chief (conflict of interest??) said last Friday. All the major local media ran front-page headlines -- despite knowing full well that the union chief would want to cover up guilt -- saying it was strong wind that caused the accident.
I'm branding that publication as subjective, equally as bad as the subjective members of the local media.

The thing about no windshear was aired early on, before even the Aussie media started talking about the possibility.

The Garuda pilot's union chief in the initial interview NEVER insisted that it was a windshear, he just said the pilot felt like "something pushed him from behind" when flaring... which CAN MEAN windshear. If you see the TV interview at the time, you would know the media frenzy screaming downdraft over the next 24hrs was a result of this interview.

I had to spend 4 hrs at a local TV station on Sunday evening lecturing them on what is possible, what isn't, and the things they've mistranslated. And the faces they had about 'Oh Sh1t! We did bad!' was countless!

I find this rather offensive...
THE MORAL OF THE STORY IS:
The Indonesians, specifically those from the most populous island, are trying once again to shift the blame and what better targets, the USA, Australia and a big Capitalist MNC (Boeing)!

They are trying again to twist the public's mind (or refocus it) so they won't have to work on fixing any of their gross problems OR be accountable for this culture of lying, cheating, shoddy maintenance or faulty pilot training methods...
Perhaps one should look into what the local aviation forum has discussed.
1. No conspiracies (dismissed by nightfall 7th evening)
2. No downdrafts (dismissed by nightfall 7th evening)
3. No sabotage (dismissed by nightfall 7th evening)
4. Pilot error possible (raised by nightfall 7th evening)
5. Mech error possible, with the types of possible failures, not just a general comment), (raised 8th evening)
6. No ATC at fault based on current evidence. (Raised Sunday).
Is that another "Bules are great and locals are dumb" publication?

Seriously!

PK-KAR
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Old 13th Mar 2007, 07:54
  #177 (permalink)  
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Two points of fact:

1. An eye witness aboard the aircraft says quite clearly that he noticed the flaps were not extended.

The account by Mr. Bertelloti is clear, straightforward and unembellished. He is observant and clear headed and is familiar enough with flying to be aware that the flaps are normally extended for landing. He is in short, a credible witness.

2. In the photographs of the remains of the aircraft the flaps are not extended.

More interestingly - they appear not to be fully retracted either. There is a small but significant gap between the trailing edge of the (partially raised) spoilers and the leading edge of the flap.

Now I speculate - and I hate to do so - but these facts suggest that the problem the crew experienced with the flaps was an asymmetry lock-out, following which they attempted a flapless landing. Which for reasons presently unknown, went badly wrong.

To learn if that is the case, we must await the findings of those conducting the investigation who will no doubt, have many more facts to work with than are available to we who are reduced to poring over photographs and newspaper reports.
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Old 13th Mar 2007, 08:11
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I've been reading the local aviation forum, as well as pprune, and I totally agree with with you that the correct info is out there. However, the journos are not printing that stuff. (btw, THE POINT is pro-govt as its main benefactor is a top minister A.B.) As a frequent traveler around the archipelago, I truly now fear stepping on planes as more comes to light about the safety culture, bribed inspectors etc.. My editorializing in the blog was not meant to offend you or anyone else (sincerely sorry if it did), it was meant as a criticism of politicians, bureaucrats, media and airline execs who already seem to be paving the way for an escape route away from the hard work of improving the safety culture.

I can almost hear the next statements coming from some gov't official: -- 'We need a gazillion more $$ to update our fleets and we're appointing General XXX to handle all the procurement...' And that saddens and frightens me.
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Old 13th Mar 2007, 08:47
  #179 (permalink)  
 
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Riccardo,
I've been told that at least one journo in Tempo magazine has printed stuff more towards the real possibilities, well, at least not in the lines of "sensationalistic journo'ism".

My editorializing in the blog was not meant to offend you or anyone else (sincerely sorry if it did), it was meant as a criticism of politicians, bureaucrats, media and airline execs who already seem to be paving the way for an escape route away from the hard work of improving the safety culture.
Well, I have no objections to this version...

PK-KAR
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Old 13th Mar 2007, 10:53
  #180 (permalink)  
 
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I apologise for not providing the link to the story about the cvr and Fdr in "The Australian".

It is my fervent wish that the Indonesian Authorities and their helpers at the ATSB and Boeing/Honeywell/FAA/whatever are working in a spirit of full and open cooperation to understand what has happened and learn from it, bearing in mind that it could happen again anywhere in the world, if the cause is not understood and dealt with.

It would be a tragedy if this investigation degenerated into a nationalistic fight and I respectfully suggest that Pprune people should do their best to arrest any trends in this direction.

I have full confidence in the Indonesian Authorities to investigate this matter properly. Indonesia is a smart country.
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