Accident investigation report: Garuda Boeing 737 crash at Yogyakarta

Indonesia's National Transportation Safety Committee (NTSC) has completed its investigation of the Garuda Indonesia accident at Yogyakarta (JOG) and has issued its report. The accident occurred on March 7, 2007 as Garuda Flight GA 200, a Boeing 737-400 aircraft, arrived at Yogyakarta on a scheduled flight from Jakarta. Garuda Flight GA 200 overran the runway at JOG, broke through a fence, crossed a road, and came to rest in a rice paddy. The aircraft was destroyed by fire after the crash. Among the seven crew members and 133 passengers who were on board, one flight attendant and 20 passengers died. One flight attendant and 11 passengers were seriously injured.

The NTSC's main finding, stated in a media release issued today, was that "...the flight crew’s compliance with procedures was not at a level to ensure the safe operation of the aircraft." More specifically, the reports says this about the actions of the pilot in command (PIC):

The aircraft was flown at an excessive airspeed and steep flight path angle during the approach and landing, resulting in an unstabilized approach. The PIC did not follow company procedures that required him to fly a stabilized approach, and he did not abort the landing and go around when the approach was not stabilized. His attention was fixated or channelized on landing the aircraft on the runway and he either did not hear, or disregarded the [Ground Proximity Warning System (GPWS)] alerts and warnings and calls from the copilot to go around.

And says this about the co-pilot:

The copilot did not follow company procedures and take control of the aircraft from the PIC when he saw that the pilot in command repeatedly ignored the GPWS alerts and warnings. The Garuda
Simulator Pilot – Proficiency Check records showed no evidence of training or proficiency checks in the vital actions and responses to be taken in the event of GPWS or EGPWS alerts and warnings, such as ‘TOO LOW TERRAIN’ and ‘WHOOP, WHOOP, PULL UP’.

Note: See the NTSC's English Language Media Release about the GA 200 accident investigation for descriptive details about the approach and landing.

The NTSC accident report also faulted Garuda International for insufficient training of the pilots, and criticized the Ministry of Transportation's Directorate General of Civil Aviation (DGCA) for ineffective surveillance of Garuda, which might have identified safety deficiencies. The report noted as well that "Yogyakarta Airport’s rescue and fire fighting services vehicles were unable to reach the accident site and some did not have appropriate fire suppressant. The delay in extinguishing the fire, and the lack of appropriate fire suppressant agents, may have significantly reduced survivability."

The NTSC report includes a number of safety-related recommendations to Indonesia's DGCA, airlines, and airports. The recommendations address "flying operations procedures, training and checking, safety and regulatory oversight and surveillance, serviceability of flight recorders, and airport emergency planning and equipment."

Related: Click here to view all posts on this blog about Garuda Flt 200.