Garuda Indonesia Flight 200
Garuda Indonesia Flight 200 was a scheduled domestic passenger flight of a Boeing 737-400 operated by Garuda Indonesia between Jakarta and Yogyakarta, Indonesia. The aircraft overran the runway, crashed into a rice field and burst into flames while landing at Adisutjipto International Airport on 7 March 2007. Twenty passengers and one crew member were killed. Both the captain and the first officer survived, but then were fired shortly after the accident occurred.
Background
Aircraft
The aircraft was a Boeing 737-497, registered as PK-GZC, which had been operated by other airlines before being acquired by Garuda Indonesia. The aircraft had accumulated over 35,200 airframe hours and 37,300 cycles since its first flight in 1992.Crew
The captain and Pilot in Command was 44-year-old Muhammad Marwoto Komar, who had been with Garuda Indonesia for more than 21 years. He had 13,421 flight hours, including 3,703 hours on the Boeing 737. The first officer was 30-year-old Gagam Saman Rohmana, who had been with the airline for three years and had 1,528 flight hours, with 1,353 of them on the Boeing 737.Garuda Indonesia
The national airline of Indonesia, Garuda Indonesia had received a number of criticisms in the months surrounding the crash. According to Australian aviation experts, Garuda Indonesia had one of the worst safety records among the world's national carriers. Since 1950, Garuda Indonesia has had 13 major accidents. The most recent was in 2002, when Garuda Indonesia Flight 421 ditched in the Bengawan Solo River due to engine flameout caused by excessive hail ingestion, killing a flight attendant. The deadliest accident was in 1997, when Garuda Indonesia Flight 152 flew into a wooded mountain on approach to Medan, killing 234 people. The managing director of the Centre for Asia Pacific Aviation, Peter Harbison, stated that the major accidents in Indonesian aviation history were all caused by the combinations of airports' and fleets' low safety standards and the poor weather conditions in the area, including severe thunderstorms and other forms of inclement weather.Following the crash of Flight 200, the European Union banned Garuda and all Indonesian airlines from flying into the EU. The ban was a watershed moment for Garuda, leading to widespread reforms within the airline to improve both its safety and service standards. It led to the implementation of the 5-year Quantum Leap improvement program. Garuda's fleet was nearly doubled with the introduction of new aircraft such as the Boeing 737-800 and Boeing 777-300ER. Garuda also added more destinations by starting or resuming service to destinations such as Amsterdam and London. The European ban on Garuda was lifted two years after the crash in June 2009, and the airline resumed service to Europe shortly afterwards with the inauguration of one-stop service from Jakarta to Amsterdam via Dubai.
Flight chronology
Flight GA200 originated in Jakarta and was carrying 133 passengers, 19 of whom were foreigners. Several Australian journalists were on the flight, covering the visit of Foreign Affairs Minister Alexander Downer and Attorney-General Philip Ruddock to Java. They were on the flight as the aircraft carrying Australian dignitaries were at capacity.At 6:58am local time, the captain attempted to land at Adisutjipto International Airport in Yogyakarta, despite a faulty approach with excess speed and steep descent, and the resulting warnings of copilot and flight system. The aircraft touched down beyond the runway threshold at a speed of, faster than the normal landing speed. According to passengers, the aircraft shook violently before it crashed. The aircraft overran the end of the runway, went through the perimeter fence, was heavily damaged when it crossed a road, and stopped in a nearby rice field. A fuel-fed fire raged, which could not be reached by airport fire-suppression vehicles. While most passengers were able to escape, a number of passengers perished inside the burning fuselage.
Captain Komar initially claimed that there was a sudden downdraft immediately before the flight landed, and that the flaps on the aircraft may have malfunctioned.
Aftermath
In a miraculous stroke of luck, one of the survivors was a freelance cameraman, Wayan Sukardo, for Channel Seven of Australia. He tumbled out of the cabin safely into a rice paddy, with his camera and, despite having a suspected broken leg and other injuries, started filming the aircraft burning up, along with shocked passengers evacuating, as well as injured passengers in the terminal of the airport, at one point also capturing a fuel tank blowing up accompanied by screams and violent shaking. He made a call to the Sydney headquarters a few minutes later, and the story was transmissed on the very same night.Investigation
The accident was investigated by the Indonesian National Transportation Safety Committee. Australian Federal Police disaster victim identification experts were deployed to the scene to assist with the identification of bodies. Australian Transport Safety Bureau staff assisted at the scene by inspecting the wreckage. The United States' National Transportation Safety Board dispatched a team to assist in the investigation, including representatives from Boeing and the Federal Aviation Administration. The flight recorders were removed from the wreckage and flown to the ATSB's headquarters for further analysis using equipment not yet available in Indonesia. Staff in Australia could not extract data from the cockpit voice recorder, which was then sent to Boeing Renton Factory in Renton, Washington to be analysed.Report of the NTSC
After the crew members were interviewed, the wreckage was examined, flight data and cockpit voice recordings were analyzed, and a safety review of the airport was conducted, Indonesia's National Transportation Safety Committee released its final report on 22 October 2007. No evidence was found of any defect or malfunction of the aircraft or its systems that could have contributed to the accident. Records showed only the right thrust reverser had been used for the previous 27 sectors, but a fault condition for the left reverser was reset by engineers before departure for this flight, and both were deployed during the landing roll. The weather was calm. It was noted that the Yogyakarta Airport did not conform to international safety standards, having a runway runoff in length, compared to the recommended length of.The key NTSC finding is that the aircraft was flown by the Pilot in Command at an excessively steep descent and high airspeed manual, and lacked coherence.
In summary, the NTSC Report attributed the accident to pilot error.
As of 1 March 2007, Garuda Indonesia had implemented a new fuel efficiency incentive, which awarded a salary bonus if fuel consumption for a flight was lower than nominal. During his interview with the NTSC, the captain denied that this had influenced his decision not to abort the landing.
Prosecution of the captain
On 4 February 2008, captain Komar was arrested and charged with six counts of manslaughter. The charge carried a penalty up to life imprisonment if the court found the crash was deliberate. Short of that finding, the lesser charge of negligent flying causing death carries a maximum sentence of seven years. The first officer testified that he had told the captain to go around because of excessive speed, and that he then had blacked out due to the severe buffeting.On 6 April 2009, the captain was found guilty of negligence and sentenced to two years of imprisonment.
The captain's lawyers stated their intention to appeal on the basis that the Convention on International Civil Aviation, to which Indonesia is a party, stipulates that aviation accident investigation reports cannot be used to ascribe blame, but only to determine cause.
The Garuda Pilots Association and Indonesian Pilots Federation threatened to strike in protest against the conviction.
On 29 September 2009 the Indonesian High Court overturned the conviction,
finding that the prosecutors had failed to prove that the pilot was “officially and convincingly guilty of a crime”.
This case was later cited in a report published by the American Bar Association, in a defence of the principle that airline safety is undermined by such prosecutions because the threat of them taking place would impede the investigative processes.