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Garuda Mishap at Yogyakarta Airport

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So basically it summarises as Inadequate Airport Planning + Pilot Error?

Though I don't really like the term "Pilot Error", it's just like blaming the frontseaters for whatever that has gone wrong and then closing the case. :angry:

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Though I don't really like the term "Pilot Error", it's just like blaming the frontseaters for whatever that has gone wrong and then closing the case. :angry:

 

I don't like the term either, but in this case, sadly it points there.

 

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From ninemsn.com.au ...

 

 

Psychological profiles under way for Garuda pilots

Sunday Apr 15 11:00 AEST

 

By Sarah Ferguson, SUNDAY

 

Crash Investigators from the Indonesia's National Transportation Safety Committee are building psychological profiles of the captain and co-pilot in order to understand the crucial last-minute decisions taken in the cockpit of Garuda Flight 200.

 

The plane plunged into a rice field at Yogyakarta last month killing five prominent Australians and 16 Indonesians. The Chairman of the crash investigators, Tatung Kurniadi, says the fatal crash may have been caused by a single moment of absent mindedness.

 

“Absent-mindedness. I worry that this accident is came from absent-mindedness from the cockpit crew,” he said.

 

The Captain of Garuda flight 200, Marwoto Komar was a veteran pilot with more than 20 years experience. In the morning before the crash, fellow Garuda pilot and head of the Indonesian Pilots Federation, Captain Manotar, says he met Marwoto in the terminal and was concerned by his behaviour.

 

“I saw him a little bit so quiet, not as usual. I think what happened to him … maybe family, maybe I don’t know 'self' problem, I think,” Captain Manotar said.

 

Garuda has regulations about the number of hours a captain can fly in a given month but Manotar thought Captain Marwoto may have been tired.

 

“I think maybe he is tired because he is flying so many hours in the month.”

 

The president of Garuda Emirsyah Satar said it was too early to say what caused the crash but he also said it was not due to systemic failure in Garuda.

 

“Accidents do happen” he said.

 

According to Kurniadi, the captain and co-pilot have already told investigators in interviews that they were at odds on what to do as they came into land, too fast and too high.

 

“Our psychological investigator asked the pilot and the pilot and the co-pilot talk about it.”

 

Kurniadi said the co-pilot is heard on the cockpit voice recorder telling the captain to go around — not to land the plane.

 

The investigators are considering whether Captain Marwoto was overly fixated on completing the landing, a profile known in Indonesian terms as “missionistic”.

 

“Sometimes even the many, many accident made by the very, very experienced pilot because it's just a split second we have to make a decision as a pilot.” He said.

 

 

http://news.ninemsn.com.au/article.aspx?id=261163

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Sounds like a "Just let me land this baby and call it a day." :huh: Fatigue issues now?

Edited by Tony

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Indonesia To Act On Flight Safety Warnings

 

April 17, 2007

Indonesia pledged on Tuesday to shut down airlines that persisted to flout safety markers, as the United States advised its citizens not to fly on the nation's airlines after a recent spate of accidents.

 

In a message sent to US citizens in Indonesia, the American embassy cited an audit by the Indonesian civil aviation agency, which revealed that no local airline was in excellent condition.

 

It also said "serious concerns" over air safety had led the US Federal Aviation Administration to downgrade Indonesia's safety oversight category from 1 to 2 indicating it was not meeting International Civil Aviation Organization standards.

 

"Whenever possible, Americans traveling to and from Indonesia should fly directly to their destinations on international carriers from countries whose civil aviation authorities meet international aviation safety standards," the embassy said.

 

The Indonesian audit of 54 aviation firms last month revealed none made it to the first of three rating classes, while six were given a warning to comply with safety regulations in three months or face closure.

 

"After three months when they've not improved then we close them," Transport Minister Hatta Radjasa told foreign journalists, referring to the airlines on closure warning -- AdamAir, Kartika Airlines, Jatayu, Batavia, Trans Wisata Air and Dirgantara.

 

The audit was ordered by the government to evaluate transport safety following deadly air accidents in recent months.

 

First, an Adam Air jet carrying 102 people disappeared in January, and on March 7 a Garuda plane overshot a runway and burst into flames, killing 21 people.

 

Radjasa, who has faced calls to resign from parliamentarians after the string of disasters, outlined a roadmap to improve the nation's shoddy transport system by 2009.

"Many of our ships are more than 20, or perhaps 30 years old, our aircraft are mostly over 20 years old and our railway track dates back to colonial era," Radjasa said.

 

He said Indonesia's patchy radar cover should be extended to cover 100 percent of national airspace by 2009, while there would be more security X-ray machines for security purposes.

 

He said that the budget for transport had been increased by 15 percent this year to around 16 trillion rupiah (USD$1.8 billion) for the transport sector, but would seek other sources of funding including the private sector for such a huge task.

 

The US embassy message said the recent accidents "raise questions about the safety practices of Indonesian air carriers and their oversight by the Indonesian Directorate General of Civil Aviation".

 

Air travel in Indonesia, a sprawling nation of more than 17,000 islands, has grown substantially since the liberalization of the sector in 1999 which triggered price wars among airlines.

 

The rapid growth caused concern over whether safety has been compromised and aviation infrastructure and personnel can cope with the huge increase.

 

In a separate written response to questions, Radjasa denied that budget airlines had operated by skimping on safety.

 

"It is not true that the budget airlines run by cutting safety related cost," he said.

 

(Reuters)

 

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Apparently the Garuda pilots flew their B737 like how I fly in MS Flight Simulator. Most of the add on packages I got like the PMDGs and Level D B767 have flap relief. So when I come in for a landing if I am too near the airfield I just put my flaps handle on the max flap position and then as my speed bled off the flaps automatically lower themselves into appropriate positions. I do not follow the speeds as commanded by my PFD depending on my mood and the way I set up my approacH!!!

Edited by Darren Liew

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The Verdict is out.

 

 

Garuda pilot ignored copilot's warnings

October 22, 2007 - 4:54PM

 

The pilot of an Indonesian plane that crashed killing five Australians was so "fixated" with landing that he ignored 15 alerts and the pleas of his copilot warning he was coming in too fast.

 

The dramatic final report into the March 7 crash reveals the copilot urged his superior to abort the landing, moments before the plane burst into flames in a field after skidding off the runway at Yogyakarta in Central Java.

 

The five Australians were among 21 people who perished - many as a result of the fire, which the report said emergency crews were ill equipped to fight.

 

More than 100 others survived but many suffered horrific burns, including Sydney Morning Herald journalist Cynthia Banham, who has since had one leg amputated and the other partially amputated.

 

The report, by the Indonesian transport ministry's National Transport Safety Committee, found chief pilot Marwoto Komar pushed ahead with the landing, despite the Boeing 737's Ground Proximity Warning System (GPWS) sounding 15 alerts and warnings.

 

The phrases "too low terrain" and "whoop whoop pull up" echoed through the cabin in English, but the pilot did not respond. Officials have ruled out a language barrier being to blame for the pilot's lack of response.

 

The alerts went off as the plane made an "unstabilised approach", coming in too fast and at a steep angle.

 

"During the approach, the Ground Proximity Warning System (GPWS) alerts and warnings sounded 15 times, and the copilot called for the pilot in command to go around," a summary of the report said.

 

"The aircraft was flown at an excessive air speed and steep flight path angle during the approach and landing, resulting in an unstabilised approach."

 

The pilot "did not abort the landing and go around when the approach was not stabilised".

 

"His attention was fixated or channelised (sic) on landing the aircraft on the runway and he either did not hear, or disregarded the GPWS alerts, and warnings, and calls from the copilot to go around," the report said.

 

It also found the copilot did not follow procedure and seize control of the plane when it became clear the pilot had ignored the warning system's alerts.

 

Fire crews at the airport were also hindered by a lack of equipment.

 

"The delay in extinguishing the fire, and the lack of appropriate fire suppressant agents, may have significantly reduced survivability," the report said.

 

"The airport emergency plan and its implementation were less than effective."

 

National Transport Safety Committee chairman Tatang Kurniadi said the report was aimed at preventing further accidents, and was not to be used as the basis for any legal action over the March crash.

 

He said the committee would not (not) hand over any evidence gained from the flight recorders to help the police investigation, angering victims' families.

 

"We will not give police or any institution (information) other than for safety purposes only ..." he said.

 

"... according to international regulations on aviation these black boxes are not allowed to be used for liability purposes."

 

The committee's report does not contain any recommendations for police action against the pilots.

 

Kurniadi said the report was about safety in the future, and not blame.

 

"(The) NTSC want to ensure there will be no terror (towards the pilot) created from this report.

 

"There's no police (action) needed, we just want to increase the safety regulations."

 

Yogyakarta police spokesman Budi Santoso said police would act on the committee's recommendations.

 

The sister of Australian Financial Review reporter Morgan Mellish, who died in the crash, travelled to Jakarta for the release of the report and said the committee must hand over any evidence it has to police.

 

Indonesian authorities must work together if they hoped to prevent similar tragedies, Caroline Mellish said.

 

"If they can't work together in different departments, I don't know how they are going to run a country and make any difference investigating this sort of accident and ensuring the recommendations do get carried forward to ensure that no more accident happen," she said.

 

Asked about the prospect that the chief pilot could be charged, she said: "I think having 21 deaths on your conscience is probably enough".

 

"I don't think prosecuting the man is going to make any difference."

 

The pilot's lawyer, Mohamad Assegaf, said his client should be praised, not prosecuted, for landing at the airport, and not on nearby built-up areas.

 

"At least he brought the plane to land on the runway, because the airport was surrounded by a densely populated area that could cause more victims," he said.

 

The other Australians who died in the crash were Australian Federal Police agents Brice Steele, 35, and Mark Scott, 41, diplomat Liz O'Neill, 37, and Australian head of AusAID Indonesia, Allison Sudradjat, 41.

 

They were travelling to Yogyakarta in association with a planned trip there by Australia's Foreign Minister Alexander Downer.

 

Australian banker Roger Tallboys, 51, from Hobart, survived but suffered burns.

 

Indonesia has had six major plane and ferry accidents over the past 18 months, killing almost 900 people.

 

Since the Garuda crash, Australia has pledged $A24 million over three years to help Indonesia improve its air and maritime safety.

 

The family of Roger Tallboys said he had received an outline of the crash report.

 

His father Richard said he was "unimpressed" with just how many failings it had revealed.

 

He said he would meet up with his son, who lives in Hong Kong, in a week or so to discuss the report.

 

"There were a lot of failings with the ground operation and fire rescue, and Roger will need to consult his insurance company and legal adviser," Richard Tallboys said.

 

He said his son still needed treatment for the skin grafts he received on his hands and legs.

 

http://www.theage.com.au/news/World/Garuda...2940973561.html

 

+++

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Interesting outcome. I wonder if co-pilots can / have the nerve to 'seize control' from the Captain in circumstances like this.... which brings to mind similar situation which led to the KLM-PanAm crash which found that the co-pilot and flight engineer dared not challenge the Captain's decision to take-off.

 

Maybe a third pilot in the cockpit can overrule the Captain through majority decision.

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Interesting outcome. I wonder if co-pilots can / have the nerve to 'seize control' from the Captain in circumstances like this.... which brings to mind similar situation which led to the KLM-PanAm crash which found that the co-pilot and flight engineer dared not challenge the Captain's decision to take-off.

 

Maybe a third pilot in the cockpit can overrule the Captain through majority decision.

 

The KLM - PanAm Tenerife crach sparked the idea of CRM. The current idea is that the co-pilot MUST take control from the captain in certain situation such as this one. Sadly way too many copilots were unable or unwilling to do so, resulting in accidents.

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The pilot's lawyer, Mohamad Assegaf, said his client should be praised, not prosecuted, for landing at the airport, and not on nearby built-up areas.

 

"At least he brought the plane to land on the runway, because the airport was surrounded by a densely populated area that could cause more victims," he said.

 

Anyone else find it shocking that the lawyer actually said this? :angry:

 

I think the image of Indonesian transportation systems are beyond repair now, I for one will never ever fly any of their carriers or take their ferries unless absolutely necessary.

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Anyone else find it shocking that the lawyer actually said this?

 

I think the image of Indonesian transportation systems are beyond repair now, I for one will never ever fly any of their carriers or take their ferries unless absolutely necessary.

Well, first of all, he is an Indonesian lawyer, what can we expect?

 

The EU ban on all aircrafts registered in Indonesia from EU's sky is a result from this incident. Knowing the Indonesians, more bans should be imposed on them to 'open' their eyes and more importantly, their mind.

 

 

 

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Lawyers shouldn't be allowed anywhere near the cockpit. :clapping: :clapping: :clapping:

 

Anyway, a bit off-topic: The 1-2-Go crash in HKT would probably point to the same reason, albeit with weather as a contributing factor.

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The KLM - PanAm Tenerife crach sparked the idea of CRM. The current idea is that the co-pilot MUST take control from the captain in certain situation such as this one. Sadly way too many copilots were unable or unwilling to do so, resulting in accidents.

Thanks for the insight into this cockpit rule Captain Radzi. Understandably some co pilots are unwilling, perhaps more so when the Captain may be instructor or director of flight operation flying next to him or her.

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Anyway, a bit off-topic: The 1-2-Go crash in HKT would probably point to the same reason, albeit with weather as a contributing factor.

And the pilot in this crash is an Indonesian as well. I bet a ban on Indonesian pilots will be imposed somewhere someday. But why must all this bad things relate to Indonesia(n)?

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Lawyers shouldn't be allowed anywhere near the cockpit. :clapping: :clapping: :clapping:

 

 

How about the few Captains-Lawyers they have in MAS?

 

I do agree that the statement made by the lawyer was really dumb.

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And the pilot in this crash is an Indonesian as well. I bet a ban on Indonesian pilots will be imposed somewhere someday. But why must all this bad things relate to Indonesia(n)?

 

Corruption sir, and one day Malaysia could be like this too......

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Corruption sir, and one day Malaysia could be like this too......

I know about it very well. I have been here (in Indonesia) for more than 2 years. But I think, corruption aside, there is something not right in their aviation system, including pilot/crew training.

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http://www.theage.com.au/news/world/garuda.../2007/10/\

23/1192941064786.html

 

Garuda pilots face sack, prosecution

 

Mark Forbes, Jakarta

October 24, 2007

 

PILOTS who crashed a Garuda plane at Yogyakarta airport, killing 21

people including five Australians, are facing dismissal and demands

from the Australian Government that they be prosecuted.

 

Garuda's operations head, Ari Sapari, told The Age the plane's pilots

could be sacked next week. But he defended a lack of emergency

training for pilots revealed by crash investigators, stating "nobody

is perfect in this entire world".

 

If the pilots were charged with criminal negligence, Garuda would

provide their defence team, Mr Sapari said. "They are still our

employees, up to now. They have the right to be assisted."

 

And Yogyakarta's runway is not being lengthened to meet international

safety standards, in spite of assurances from Indonesia's transport

minister and aviation authorities that work was under way.

 

In March, the jet overshot the runway, crashing through fencing and a

roadway before bursting into flames.

 

Hidden in the fine print of the crash report is a statement from the

state-owned airport operator that "the airport does not have the land"

to build the required 90-metre runway end safety area. A study of

engineering alternatives could be completed by next June, the company

states.

 

Other major Indonesian airports that failed safety standards would be

upgraded, "step by step", beginning next year with Denpasar, Surabaya,

and Makassar, the operator said.

 

Prime Minister John Howard yesterday said he was "quite astonished"

that the Boeing 737's captain ignored 15 loud alarm calls before

trying to land in March.

 

Foreign Minister Alexander Downer demanded prosecutions. "I want to

see people who have negligently allowed Australians … to be killed, I

want to see those people brought to justice," he said.

 

The "chilling" investigator's report made it "pretty clear that the

pilots were responsible for the accident", Mr Downer said.

 

"I've asked our ambassador today to make it absolutely clear to the

Indonesians that we want people prosecuted for this accident."

 

Opposition Leader Kevin Rudd phoned the head of Indonesia's Department

of Foreign Affairs yesterday to tell him Australians expected the

investigation to be "prosecuted to the absolute full".

 

Chairman of Indonesia's National Transportation Safety Committee,

Tatang Kurniadi, yesterday confirmed air safety investigators would

refuse to discuss the case with police because "it means collusion".

 

Under international aviation protocols, crash investigators could only

testify to a court hearing, Mr Kurniadi said.

 

Garuda's safety committee is expected to announce action against the

pilots next week. It could include dismissal, Mr Sapari said. Both had

been grounded since the crash. Since then, all Garuda pilots had had

training to abort a landing when warning alarms sounded.

 

With BRENDAN NICHOLSON

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