The crash of the Boeing 737 in Yogyakarta

Boeing 737-497 (registration number PK-GZC, serial number 25664, serial 2393) was released in 1992 (the first flight took place on November 5). Equipped with two CFM International CFM56-3C1 turbofan engines . Operated by airlines:

• Aloha Airlines - from November 13, 1992 to April 23, 1996 (board N402AL),
• Star Europe - from April 23, 1996 to October 28, 1997 (board F-GRSC),
• Jet Airways - from October 28, 1997 to October 7, 2002 (VT-JAP board).

October 7, 2002 was purchased by Garuda Indonesia and received a tail number PK-GZC. On the day of the disaster, he made 37,360 take-off and landing cycles and flew 35,207 hours ^{[1] [2]} .

The aircraft was controlled by an experienced crew, the composition of which was as follows:

• The commander of the aircraft (FAC) is 44-year-old Muhammad Marvoto Komar ( indon. Muhammad Marwoto Komar ). A very experienced pilot, worked at Garuda Indonesia for 21 years and 4 months (from October 16, 1985). I flew 13,421 hours 9 minutes, 3,703 hours 59 minutes of them on the Boeing 737-400.
• The co - pilot is the 30-year-old Gagam Saman Rahman ( indon. Gagam Saman Rohmana ). An experienced pilot, worked at Garuda Indonesia for 2 years and 8 months (since July 19, 2004). Flown 1528 hours 40 minutes, 1353 hours 55 minutes of them on the Boeing 737-400.

In the cabin, 5 cabin crew worked.

GA200 flight departed from Jakarta at 04:30 WIB and headed for Yogyakarta. On board were 7 crew members and 133 passengers.

At 07:17, when approaching the runway, the FAC specified the altitude and course data from the second pilot and started to lower, having previously informed the passengers about it. The commander focused on landing the aircraft, which led him to a state of fixation (in this state, the person focuses only on one task and may not respond to the outside world - loud sounds, bright light).

When approaching the lane, the commander did not respond to the rather loud alarm GPWS , because of which the crew should go to the second round. The PIC gave the order to release the flaps by 15 °, but the co-pilot did not translate them into this position, since the speed of the aircraft, which the PIC did not follow due to the fixation state, was great for changing the position of the flaps (they could be torn off).

The alarm ("MASTER CAUTION") did not stop, the commander repeated the order, but the co-pilot did not respond. Why the co-pilot did not report the inadmissibility of a change in the position of the flaps remained unclear.

At 07:58 a.m. WIB, when touching the runway with the flaps in the wrong position, flight GA200 jumped up and went into a goat . With a second touch, the nose landing gear formed, the liner traced the entire runway with its nose, rolled out onto the rice field (when it was rolled out, the nose part with the cockpit and the right wing, ignited by impact) came off and stopped. Killed 21 people (20 passengers and 1 flight attendant), another 112 were injured of varying severity.

NTSC Report

An investigation into the causes of the GA200 flight crashes was undertaken by the National Transport Safety Committee (NTSC) .

The final report of the investigation was published on October 22, 2007.

According to the report, the right thrust reverse was used for the previous 27 sectors, but the left reverse failure condition was reset by the engineers before the departure of flight 200, and both were deployed during landing in Yogyakarta. The weather was calm. It was also noted that the Yogyakarta airport did not meet international safety standards, with a runway runoff of 90 meters ^[3] .

The key conclusion of NTSC is that the FAC operated the aircraft with an excessively steep descent and high flight speed of 446 km / h, and not at normal 261 km / h during approach and landing, which led to an unstable flight. The commander’s attention was focused on landing from the first approach, and he ignored the warnings of the co-pilot and his recommendations about going to the second round, as well as GPWS signals “SINK RATE!” And “WHOOP! WHOOP! PULL UP! ” The co-pilot was unable to take control of the ship in these circumstances, presumably due to poor preparation. The flaps were not fully released up to 40 ° and not even up to 15 °, but only at 5 ° (the co-pilot knew that this was the recommended maximum for such a high flight speed, but did not inform the commander about this).

Landing, followed by a goat, began 240 meters before the nominal touchdown zone. The nose gear was damaged and broken during the second jump. Thrust reversals were deployed 4 seconds after landing and continued for 7 seconds, but were removed 7 seconds before the liner rolled out of the runway and broke through the airport fence. Approximately 160 meters from the end of the runway, Flight 200 crossed a small ditch and an adjacent road that is 1-2 meters below the level of the runway and rice field. The nose of the liner crashed into a road embankment and broke off, and both engines damaged a concrete curb directly in front of the embankment. The liner stopped in a rice field 252 meters from the runway.

Jet fuel leaked from the main tank ignited. Yogyakarta Airport fire engines could not reach the crash site through a broken fence due to the embankment, the ditch between them and the road. As a result, the first firefighters arrived at the scene of the disaster only after 45 minutes. In addition, firefighters were not able to apply enough foam to extinguish the fire, because the hose that they dragged across the road was broken by rescue vehicles and other vehicles, as well as by a broken airport fence. The fire was extinguished 2 hours and 10 minutes after the disaster.

As of March 1, 2007, Garuda Indonesia introduced a new incentive to improve the efficiency of using aviation fuel, which provides a salary bonus if the fuel consumption for a flight was below the nominal. During interrogation by NTSC investigators, the FAC denied that this influenced his decision not to interrupt the landing.

Crew Commander's Arrest

On February 4, 2008, flight crew commander Muhammad Marvoto Komar was arrested, a criminal case was opened against him and charges of murder were brought ^{[4] [5]} . He was threatened with life imprisonment if the court would prove the intentions of his actions, which caused a catastrophe, but if his actions were recognized as unintentional, he would face up to 7 years in prison ^[6] . The co-pilot in the testimony stated that he had suggested the PIC to go to the second round ^[7] , but he did not react. On April 6, 2009, Muhammad Marvoto Komar was found guilty of negligence and sentenced to 2 years in prison ^[8] .

Lawyers tried to challenge the court’s verdict on the basis of the ICAO Convention, according to which the crash investigation report cannot be used to prove the guilt of any person ^[9] . The Garuda Indonesia Pilot Association and the Indonesia Pilot Federation threatened to strike in protest of the verdict. ^[10]

On September 29, 2009, the Supreme Court of Indonesia dropped all charges against Komar ^[11] , noting that the prosecutor’s office was unable to convincingly prove the pilot’s guilt ^[12] . This case was later referred to in the report of the American Bar Association ^[12] .

Garuda Indonesia, in deference to the 21 dead on Flight 200, changed the Jakarta-Yogyakarta flight number from GA200 to GA202; Boeing 737-800 flies on it.

• The crash of Flight 200 was shown in the 15th season of the Canadian documentary television series Investigation of Air Crash in the Fatal Mistake series (not to be confused with the eponymous series 11 of the season).
• A detailed analysis of this disaster was also made in a documentary shown on the National Geographic Channel on March 8, 2017. According to the participants of the film, the cause of the disaster was the poor quality of training (especially during take-off and landing) and the extremely low coherence of the pilots (lack of initiative of the co-pilot with obvious problems at the FAC), as well as (probably) the fuel efficiency policy of Garuda Indonesia. Later, the airline complied with all the recommendations and improved its reputation.

• The crash of the Boeing 737 near Yogyakarta - the disaster of another Boeing 737 airline Garuda Indonesia. It happened 7 years earlier and for other reasons.
• Newark MD-11 accident - similar in circumstances
• Disaster MD-11 in Tokyo - similar in circumstances

• Description of the disaster on the Aviation Safety Network
• NTSC Investigation Final Report