ASN Aircraft accident Boeing 737-497 PK-GZC Yogyakarta-Adisutjipto Airport (JOG)

Home » Database » 2007

Status:	Accident investigation report completed and information captured
Date:	Wednesday 7 March 2007
Time:	07:58
Type:	Boeing 737-497
Operator:	Garuda Indonesia Airways
Registration:	PK-GZC
MSN:	25664/2393
First flight:	1992-11-05 (14 years 4 months)
Total airframe hrs:	35207
Cycles:	37360
Engines:	2 CFMI CFM56-3C1
Crew:	Fatalities: 1 / Occupants: 7
Passengers:	Fatalities: 20 / Occupants: 133
Total:	Fatalities: 21 / Occupants: 140
Aircraft damage:	Destroyed
Aircraft fate:	Written off (damaged beyond repair)
Location:	Yogyakarta-Adisutjipto Airport (JOG) ( Indonesia)
Crash site elevation:	107 m (351 feet) amsl
Phase:	Landing (LDG)
Nature:	Domestic Scheduled Passenger
Departure airport:	Jakarta-Soekarno-Hatta International Airport (CGK/WIII), Indonesia
Destination airport:	Yogyakarta-Adisutjipto Airport (JOG/WARJ), Indonesia
Flightnumber:	GA200

Narrative:
Garuda flight 200 was an early morning service from Jakarta (CGK) to Yogyakarta (JOG). The pilot in command (PIC) was the pilot flying, and the copilot was the support/monitoring pilot.
The PIC intended to make an instrument landing system (ILS) approach to runway 09 at Yogyakarta and briefed the copilot accordingly. Yogya Approach cleared the aircraft for a visual approach, with a requirement to proceed to long final and report runway in sight. Although the crew acknowledged the visual approach clearance, they continued with the ILS approach, but did not inform the controller. The descent and approach were conducted in visual meteorological conditions.
At 07:55:33, 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. The pilot in command descended the aircraft steeply in an attempt to reach the runway, but in doing so, the airspeed increased excessively. As the aircraft was being flown at speeds that were in excess of the wing flaps operation speed, the copilot elected not to extend the flaps as instructed by the PIC. During the approach, the Ground Proximity Warning System (GPWS) alerts and warnings sounded 15 times and the copilot called for the PIC to go around.
The PIC continued the approach with flaps 5 degrees, and the aircraft attained the glideslope near the runway 09 threshold. Flaps 5 degrees is not a landing flap setting. The aircraft crossed the threshold, 89 feet above the runway, at an airspeed of 232 knots, 98 knots faster than the required landing speed for flaps 40 degrees. The wind was north easterly at 9 knots. The groundspeed was 235 knots. The aircraft touched down at an airspeed of 221 knots, 87 knots faster than landing speed for 40 degrees flap. Shortly after touching down, the copilot called, with high intonation, for the PIC to go around.
The aircraft overran the departure end of runway 09, to the right of the centerline at 110 knots. The aircraft crossed a road, and impacted an embankment before stopping in a rice paddy field 252 meters from the threshold of runway 27 (departure end of runway 09). The aircraft destroyed by the impact forces and an intense, fuel-fed, post-impact fire.

Probable Cause:

CAUSES:
"1. Flight crew communication and coordination was less than effective after the aircraft passed 2,336 feet on descent after flap 1 was selected. Therefore the safety of the flight was compromized.
2. The PIC flew the aircraft at an excessively high airspeed and steep descent during the approach. The crew did not abort the approach when stabilized approach criteria were not met.
3. The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the copilot to go around.
4. The copilot did not follow company instructions and take control of the aircraft from the pilot in command when he saw that the pilot in command repeatedly ignored warnings to go around.
5. Garuda did not provide simulator training for its Boeing 737 flight crews covering vital actions and required responses to GPWS and EGPWS alerts and warnings such as TOO LOW TERRAIN and WHOOP, WHOOP PULL UP."

Accident investigation:

Investigating agency:	NTSC Indonesia
Status:	Investigation completed
Duration:	209 days (7 months)
Accident number:	KNKT.07.03.05.04
Download report:	Final report

Classification:

High speed landing
Non-adherence to procedures
Landing after unstabilized approach
Runway excursion

Sources:

» SKYbrary
» KNKT
» NTSB

Follow-up / safety actions

NTSC issued 29 Safety Recommendations

Issued: --	To: DGCA Indonesia	R.2008.5.1
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators train and check their crews, in the simulator, for the vital actions and required responses to GPWS and EGPWS warnings.
Issued: --	To: DGCA Indonesia	R.2008.5.10
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and
Issued: --	To: DGCA Indonesia	R.2008.5.11
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years; and
Issued: --	To: DGCA Indonesia	R.2008.5.12
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies; and
Issued: --	To: DGCA Indonesia	R.2008.5.2
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators have published procedures that take into consideration the runway end safety area (RESA) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.
Issued: --	To: DGCA Indonesia	R.2008.5.3
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review its policy, procedures and implementation of flight operations surveillance, to ensure that DGCA achieves and maintains, adequate and appropriate regulatory oversight.
Issued: --	To: DGCA Indonesia	R.2008.5.4
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators have procedures to provide: a. the passenger lists to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin b. the cargo manifest to the crisis center, rescue and fire fighting services and the National Transportation Safety Committee, within 1 hour, to enable hazard mitigation at the accident site.
Issued: --	To: DGCA Indonesia	R.2008.5.5
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the procedures used by airline maintenance organizations for ensuring that flight recorders meet the relevant manufacturers specifications with respect to specific aircraft systems such as EFIS or non-EFIS systems.
Issued: --	To: DGCA Indonesia	R.2008.5.6
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the Yogyakarta runway complex to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14. If the DGCA is unable to meet the RESA Standard in accordance with ICAO Annex 14, it should file a difference with ICAO as soon as possible.
Issued: --	To: DGCA Indonesia	R.2008.5.7
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they : a. meet the minimum requirements specified in the ICAO Annex 14; and b. meet the rquirements to cover the area up 5 NM (8km) from the airport perimeters, as stated in the Transport Ministry Decree 47 (KM47).
Issued: --	To: DGCA Indonesia	R.2008.5.8
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and
Issued: --	To: DGCA Indonesia	R.2008.5.9
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.1
The National Transportation Safety Committee recommends that the Yogyakarta airport operator review the Yogyakarta runway complex to ensure that the runway end safety area (RESA) meets the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14.
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.2
The National Transportation Safety Committee recommends that airport operators review the procedures and equipment used by airport Rescue and Fire Fighting Services
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.3
The National Transportation Safety Committee recommends that airport operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.4
Publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.5
Have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.6
Review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.7
Exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.8
Review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard;
Issued: 07-MAR-2008	To: Angkasa Pura I Branch Office Adisutjipto International Airport	B.2008.5.9
Ensure that any identified deficiencies are corrected.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.1
The National Transportation Safety Committee recommends that Garuda Indonesia review its fuel conservation incentive program policy to ensure that flight crews are in no doubt about its intent, and that there is no perception that such a policy could compromize the safe operation of aircraft.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.2
The National Transportation Safety Committee recommends that airline operators ensure that their flight crews are trained and checked, in GPWS specific simulator training sessions, for the vital actions and required responses to Ground Proximity Warning System (GPWS) and Enhanced Ground Proximity Warning System (EGPWS) warnings.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.3
The National Transportation Safety Committee recommends that airline operators review the procedures used by their maintenance organizations for ensuring that flight recorders meet the relevant manufacturers specifications with respect to specific aircraft systems such as Electronic Flight Instrument Systems (EFIS) or non-EFIS systems.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.4
The National Transportation Safety Committee recommends that airline operators ensure that published procedures take into consideration the runway end safety area (RESA) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.5
The National Transportation Safety Committee encourages the use of the Flight Safety Foundation (FSF) Approach-and-landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness training material by Indonesian airlines. The NTSC recommends that airline operators include ALAR and CFIT awareness modules in their recurrency training programs, and conduct initial ALAR and CFIT training for flight crew members who have not yet completed such training.
Issued: 07-MAR-2008	To: Garuda Indonesia	O.2008.5.6
ensure the passenger lists to be sent to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin and the cargo manifest to be sent to the crisis center, rescue and fire fighting services and the National Transportation Safety Committee, within 1 hour, to enable hazard mitigation at the accident site
Issued: 07-MAR-2008	To: DGCA Indonesia	R.2008.5.13
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators ensure that any identified deficiencies are corrected.
Issued: 07-MAR-2008	To: DGCA Indonesia	R.2008.5.14
The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.

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Photos

accident date: 07-03-2007
type: Boeing 737-497
registration: PK-GZC

Aircraft history

date	registration	operator	remarks
05 NOV 1992	N402AL	Aloha Airlines
23 APR 1996	F-GRSC	Star Europe
28 OCT 1997	VT-JAP	Jet Airways
11 JUN 2002	N664AL	AFTTS 1	returned
04 OCT 2002	PK-GZC	Garuda Indonesian Airways	leased

Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Jakarta-Soekarno-Hatta International Airport to Yogyakarta-Adisutjipto Airport as the crow flies is 454 km (284 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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