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Garuda Crash Investigation: Pilot Error  
User currently offlineBuyantUkhaa From Mongolia, joined May 2004, 2872 posts, RR: 3
Posted (6 years 9 months 1 week 5 days 14 hours ago) and read 4333 times:

http://news.bbc.co.uk/2/hi/asia-pacific/7056444.stm

Quote:
A plane crash in Indonesia which killed 21 people in March has been blamed on pilot error by the official inquiry.
The Garuda Indonesia flight crashed on landing at Yogyakarta airport in March, and burst into flames.

[..]

Indonesia's transport safety committee said the pilot was going 60% faster than he should have been on landing. The report said the pilot ignored the aircraft's warning system, which sounded alarms 15 times during the approach. He also ignored calls from the co-pilot to go around and take the approach again. On landing, the plane over-shot the runway and burst into flames.

Rescue vehicles at the airport were unable to reach to accident site and some did not have the right fire suppressant. The report said that these factors may have cost many lives.

[...]



I scratch my head, therefore I am.
9 replies: All unread, jump to last
 
User currently offlineBok269 From United States of America, joined May 2007, 2105 posts, RR: 0
Reply 1, posted (6 years 9 months 1 week 4 days 2 hours ago) and read 3988 times:

A real shame that so many had to die. Hopefully Garuda and the Indonesian authorities can imporve their policies to prevent such a tragedy from ever occuring again.


"Reality is wrong, dreams are for real." -Tupac
User currently offlineLTBEWR From United States of America, joined Jan 2004, 13040 posts, RR: 12
Reply 2, posted (6 years 9 months 1 week 4 days 2 hours ago) and read 3958 times:

If the reports of the pilot and FO ignoring the signal they were going too fast on approach, then there may be a serious issue of cockpit management. Sounds like their flyboys need to be educated about cockpit management at an independent facility to their airline, perhaps one at another Asian based airline with such programs to improve their pilots and so for example a FO to override a main pilot if they are doing something wrong and risky.

User currently offlineMandala499 From Indonesia, joined Aug 2001, 6768 posts, RR: 76
Reply 3, posted (6 years 9 months 1 week 3 days 18 hours ago) and read 3841 times:

In Indonesia the problem is twofold.
1. We still got captains who think CRM is just another useless requirement.
2. We got F/Os who forget that their intervention can be covered by company SOP and CRM guidelines and courses.

The new findings is that they deemed the training in Garuda has been inadequately supervised by the DGAC therefore deficiencies were not caught out by the regulators.

There have been F/O interventions (forceful and declared intervention to conduct a go/around) in GA, and I recall 2 cases in the past 12 months which was supported by Garuda's Flight Ops, Crew chiefs and the safety auditors.

The final report is available for download... although give it a few more days, EVERYONE is downloading even today...

LBTEWR, Honestly speaking, I wouldn't trust those "independent facilities" too much! There are good ones but there are really really bad ones!

Mandala499



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineA390 From South Africa, joined Sep 2005, 204 posts, RR: 0
Reply 4, posted (6 years 9 months 1 week 3 days 17 hours ago) and read 3749 times:

Here is the accident report in full.

http://www.dephub.go.id/knkt/ntsc_av...al%20report%20PK-GZC%20Release.pdf


User currently offlineBaroque From Australia, joined Apr 2006, 15380 posts, RR: 59
Reply 5, posted (6 years 9 months 1 week 3 days 17 hours ago) and read 3740 times:

Very sad conclusions, but hardly a surprise.

I am not a little dismayed that the Aus Foreign Minister and Rudd both have seen fit to advise the GoI on what to do next. I would have thought that GoI could manage to figure that out by themselves without outside "help".


User currently offlineAllrite From Australia, joined Aug 2007, 2009 posts, RR: 4
Reply 6, posted (6 years 9 months 1 week 3 days 15 hours ago) and read 3606 times:

Australian newspapers are expressing a lot of outrage (eg one survivor's piece) over the decision not to charge the pilot. Then again, criticising the Indonesian judicial system is a favourite pastime of the press here.

Update: ABC News are now reporting that police are gathering evidence to pursue manslaughter charges against the pilots.

[Edited 2007-10-24 06:33:42]


Applying insanity to normality
User currently offlineAllrite From Australia, joined Aug 2007, 2009 posts, RR: 4
Reply 7, posted (6 years 9 months 1 week 3 days 14 hours ago) and read 3586 times:

Update: ABC News are now reporting that police are gathering evidence to pursue manslaughter charges against the pilots.


Applying insanity to normality
User currently offlineMandala499 From Indonesia, joined Aug 2001, 6768 posts, RR: 76
Reply 8, posted (6 years 9 months 1 week 3 days 13 hours ago) and read 3534 times:

People and governments need to understand the following things:
1. An Accident Investigation is to find out what happened, what went wrong, and how to prevent such a repeat.
2. A Criminal Investigation is to find out what happened, what went wrong, and who is responsible.

The NTSC report shall NEVER apportion blame if it is to comply with Annex 13 of ICAO. This report seems to have a long list of safety recommendations, perhaps the longest by the NTSC to date.

Now, I think the GoAustralia is a bit too quick in asking Indonesia in bringing those responsible to the courts. After the accident investigation is complete, the criminal investigations can now begin (the police did try to investigate before under presidential order to see whether a terrorist act was committed, but upon finding none, they went on to commence criminal investigations which outraged everyone!).

The Jogjakarta police is now conducting its investigations. Experts are calling for an objective investigations, and must not contravene the nation's aviation law (ie: the police cannot force the NTSC to assist, only the court can).

Mandala499



When losing situational awareness, pray Cumulus Granitus isn't nearby !
User currently offlineBaroque From Australia, joined Apr 2006, 15380 posts, RR: 59
Reply 9, posted (6 years 9 months 1 week 3 days 13 hours ago) and read 3523 times:

Quoting Allrite (Reply 6):
Australian newspapers are expressing a lot of outrage (eg one survivor's piece) over the decision not to charge the pilot. Then again, criticising the Indonesian judicial system is a favourite pastime of the press here.

After the Haneef effort, while our court was just fine, the DPP and Fed police need to lift their game. The Indonesian court system will by and large do much better without Downer blowing in the ear of GoIndonesia. Do they want GoIndia telling them how to compensate Haneef?

The recent mercury poisoning case in N Sulawesi seemed to mark a patch of sanity in the Indonesian court efforts so maybe they are on the mend. It has been known that amalgamation and retorting of the mercury gold amalgam on the banks next to rice paddies was a health issue for close to 30 years!!

It looks as if the Indonesian police will move without any assistance from Aus thank you very much.


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