Accident Boeing 737-497 PK-GZC, Wednesday 7 March 2007
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Date:Wednesday 7 March 2007
Time:07:58
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different    
Boeing 737-497
Owner/operator:Garuda Indonesia Airways
Registration: PK-GZC
MSN: 25664/2393
Year of manufacture:1992
Total airframe hrs:35207 hours
Cycles:37360 flights
Engine model:CFMI CFM56-3C1
Fatalities:Fatalities: 21 / Occupants: 140
Other fatalities:0
Aircraft damage: Destroyed, written off
Category:Accident
Location:Yogyakarta-Adisutjipto Airport (JOG) -   Indonesia
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Jakarta-Soekarno-Hatta International Airport (CGK/WIII)
Destination airport:Yogyakarta-Adisutjipto Airport (JOG/WARJ)
Investigating agency: NTSC
Confidence Rating: Accident investigation report completed and information captured
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.

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:
cover
  
Investigating agency: NTSC
Report number: KNKT.07.03.05.04
Status: Investigation completed
Duration: 6 months
Download report: Final report

Sources:

SKYbrary 
KNKT
NTSB

Statistics

  • 10th worst accident in 2007
  • 4th worst accident of this aircraft type
  • 4th worst accident of this aircraft type at the time

Location

Images:


photo (c) I. Yulistiono; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 07 March 2007


photo (c) Tsuyoshi Tsuda; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 08 March 2007


photo (c) I. Yulistiono; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 07 March 2007


photo (c) I. Yulistiono; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 07 March 2007


photo (c) National Transportation Safety Committee (NTSC); Yogyakarta-Adisutjipto Airport (JOG/WARJ); March 2007


photo (c) National Transportation Safety Committee (NTSC); Yogyakarta-Adisutjipto Airport (JOG/WARJ); March 2007


photo (c) National Transportation Safety Committee (NTSC); Yogyakarta-Adisutjipto Airport (JOG/WARJ); March 2007


photo (c) National Transportation Safety Committee (NTSC); Yogyakarta-Adisutjipto Airport (JOG/WARJ); March 2007


photo (c) Tsuyoshi Tsuda; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 08 March 2007


photo (c) Tsuyoshi Tsuda; Yogyakarta-Adisutjipto Airport (JOG/WARJ); 08 March 2007

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