Wednesday, 7th of March, 2007

– Indonesia

Garuda flight 200, a domestic scheduled passenger flight from Jakarta-Soekarno-Hatta International Airport (CGK/WIII), Indonesia, to Yogyakarta-Adisutjipto Airport (JOG/WARJ), Indonesia, operated with a Boeing 737-497, registration PK-GZC, overran the departure end of runway during a landing attempt at Yogyakarta-Adisutjipto Airport (JOG/WARJ), Indonesia.

The airplane was destroyed. One crew member and twenty passengers perished. The remaining six crew members and 113 passengers survived. (21 fatalities, 119 survivors)

The crash of Flight 200 is the fourth deadliest accident involving the Boeing 737-400.

– Details:

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.

– 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 compromised.

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’.

Other Factors:

1) The airport did not meet the ICAO Standard with respect to runway end safety areas.

2) The airport did not meet the ICAO Standard with respect to rescue and fire fighting equipment and services for operation outside the airport perimeter and in swampy terrain.”