On 7 March 2007, Garuda Indonesia flight GA200, a Boeing B737-497 registered PK-GZC , was being operated by Garuda Indonesia on an instrument flight rules (IFR), scheduled passenger service, from Soekarno-Hatta Airport, Jakarta to Adi Sucipto Airport, Yogyakarta. There were two pilots, five flight attendants, and 133 passengers on board.
The pilot in command (PIC) and copilot commenced duty in Jakarta at about 21:30 Coordinated Universal Time (UTC), or 04:30 local time, for the flight to Yogyakarta.
Prior to departing Jakarta, during the push back, the PIC contacted the ground engineers and informed them that the number 1 (left) engine thrust reverser fault light on the cockpit instruments had illuminated.
The engineers reset the thrust reverser in the engine accessories unit and the fault light extinguished.
The scheduled departure time of Garuda Indonesia flight GA200 was 23:00. The aircraft took off from Jakarta at 23:17, and the PIC was the pilot flying for the sector to Yogyakarta. The copilot was the monitoring/support pilot.
During the cruise, just before top of descent, the crew was instructed by Jakarta Control to ‘maintain level 270 and contact Yogya Approach . The copilot acknowledged.
The PIC started to give a crew briefing at 23:43 stating: ‘in case of holding, heading of 096’. The briefing was interrupted by a radio transmission from Yogya Approach, giving GA200 a clearance to Yogyakarta via airway W 17 for runway 09, and a requirement to report when leaving flight level 270.
When radio communication was completed, the PIC continued with the crew briefing for an ILS approach, stating:
“When clear approach ILS runway 09, course 088. Frequency 109.1 , aerodrome elevation three hundred fifty, leaving two thousand five hundred by 6 point 6 DME ILS, to check four DME one thousand six hundred seventy, crossing two DME one thousand thirty seven. Decision Altitude ILS Cat I, five eight seven, two three seven both set, approach flap forty, auto brake two. Speed one three six, one five one, two twenty. Timing from final approach-fix to VOR 6 DME.
With airspeed approximately one four one, two minutes thirty six. In case localizer, MDA seven hundred, localizer, missed approach, at point six. DME ILS India Juliet Oscar golf.
On landing, to the left standby parking stand.
Go-around missed approach climb one thousand five hundred turn left. To holding fix via Yogya VOR, continue climb four thousand feet, to cross Yogya at or above two thousand five hundred DME eight.”
Twelve minutes and 17 seconds later, Yogya Approach cleared GA200 ‘for visual approach runway zero nine, proceed to long final, report runway in sight’. The copilot acknowledged the clearance and asked for confirmation that they were cleared to descend to circuit altitude, Yogya Approach replied ‘descend to two thousand five hundred initially’.
The crew informed the investigation that they were conducting an Instrument Landing System (ILS) approach to runway 09 , in visual meteorological conditions (VMC). However they did not inform Yogya Approach or Yogyakarta Tower that they were flying the 09 ILS approach.
At 23:58:10, Garuda Indonesia flight GA200 overran the departure end of runway 09 at Yogyakarta Airport. The PIC reported that as the aircraft was about to leave the runway, he shut down both engines.
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 was destroyed by the impact forces and an intense, fuel-fed, post-impact fire.
There were 119 survivors. One flight attendant and 20 passengers were fatally injured. One flight attendant and 11 passengers were seriously injured.
The SSFDR data shows that 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 (134 knots) at the aircraft’s landing weight of 53,366 kilograms.
Shortly after touching down, the copilot of Garuda Indonesia flight GA200 called, with high intonation, for the PIC to go around.
The aircraft bounced twice, touching down on the main landing gear before the nose landing gear touched the ground. At the third (final) touchdown, the nose landing gear touched down heavily before the main landing gear.
The g force was about +2.91 g, and the aircraft’s pitch angle was about -1 degree (nose down).
Main-wheel tire marks and nose-wheel axle and oleo impact and scraping marks were found along the runway .
The aircraft initially tracked along the runway centerline, but it left the sealed runway about 10 meters to the right of the runway centerline leaving nose landing gear wreckage along the runway.
About 160 meters from the end of runway 09, the aircraft crossed a road and the nose of the aircraft impacted an embankment as the engines impacted a concrete gutter.
- 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.
- 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.
- The pilot in command did not act on the 15 GPWS alerts and warnings, and the two calls from the copilot to go around.
- 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
- Garuda Indonesia 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’.