Indonesia’s National Transportation Safety Committee’s (NTSC) final report into this year’s fatal Garuda crash at Yogyakarta airport has found the aircraft landed too fast and in the report the NTSC has criticised the aircraft’s pilot, co-pilot, the airline, the Indonesian civil aviation authority and the airport operator.
The NTSC says in a statement that the Garuda Boeing 737-400, registration PK-GZC, that crash landed at Jogyakarta airport on 7 March had too steep an approach and landed at too high a speed.
“The pilot-in-command descended the aircraft steeply in an attempt to reach the runway but in doing so the airspeed increased excessively,” says the NTSC, adding that “the aircraft touched down at a speed of 221 knots, 87 knots faster than the landing speed for a 40 degrees flap.”
Because the aircraft “was being flown at speeds that were in excess of the wing flaps operation speed, the co-pilot elected not to extend the flaps as instructed by the pilot-in-command” so the aircraft ended up touching down with flaps at five degrees which “is not a landing flap setting”.
As the aircraft was coming into land the aircraft’s ground proximity warning system (GPWS) sounded 15 times and the co-pilot called for the pilot-in-command to abort the landing and go round, it says.
The NTSC says the pilot-in-command ignored the co-pilot and the GPWS warnings because he became fixated on landing.
It says the pilot-in-command failed to follow company procedures which “require him to fly a stabilised approach” and the NTSC says he should have aborted the landing and gone around.
The report also criticises the co-pilot for failing to follow company procedures and says the Garuda basic operation manual states the co-pilot is to take over control of the aircraft and execute a go around when an unsafe condition exists.
It says the time for the co-pilot to act was when it became apparent the pilot-in-command was repeatedly ignoring the GPWS warnings.
While the report focuses on pilot error, it is also critical of the Directorate General of Civil Aviation (DGAC) for failing to properly fulfil its oversight role as a regulator.
“The DGAC’s flying operations surveillance of Garuda was not effective in identifying” lapses in Garuda’s pilot training, says the NTSC.
“The records show no evidence that the co-pilot had been checked or received simulator training in the appropriate vital actions and responses required to retrieve a perceived or real situation that might compromise the safe operation of the aircraft.”
Angkasa Pura I, the operator of Jogyakarta airport, also came in for criticism because the NTSC found that the airport’s “rescue and fire-fighting 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 fire suppressant may have” made it much harder for people to survive the crash, it adds.
Of the 140 people on board, 21 were killed.
Source: FlightGlobal.com
