Question of Intent: The crash of Garuda Indonesia flight 200
On the 7th of March 2007, a Garuda Indonesia Boeing 737 touched down hard on landing in Yogyakarta, sending the plane careening off the runway and into a rice paddy. As passengers scrambled to escape, jet fuel ignited beside the passenger cabin, causing a rapidly-spreading fire that claimed the lives of 21 people.
As experts converged on the scene, they saw the crash not as an isolated event, but as the latest tragedy in a long string of accidents and incidents involving Indonesia’s flag carrier. For regulatory authorities, the crash in Yogyakarta was the last straw, prompting the European Aviation Safety Agency to ban all Indonesian airlines from Europe. Meanwhile, investigators from Indonesia, Australia, and the United States set about piecing together the string of human errors that led to the crash. What they found was shocking: the captain had insisted on landing despite an extreme airspeed and descent rate, ignoring numerous alarms and warnings before slamming the plane into the runway at incredible speed. What compelled him to do something so blatantly risky? And why didn’t he listen when his first officer screamed at him to go around? The answers to both questions would play out not only during the investigation, but also in the courtroom afterwards, as the captain faced a controversial criminal trial over whether his actions rose to the level of manslaughter.
Garuda Indonesia flight 200 was a regularly scheduled domestic flight from the Indonesian capital of Jakarta to the city of Yogyakarta, farther east on the island of Java. Yogyakarta (pronounced “jog-yakarta”) is a unique semi-autonomous city administered as a hereditary sultanate, retaining some aspects of its political structure that predate its incorporation into the modern state of Indonesia. Home to more than four million people, the city is also an important cultural, religious, and educational center, and hosts some of Indonesia’s most prestigious institutions of higher learning.
Garuda Indonesia, Indonesia’s flag carrier, operated the popular route between Jakarta and Yogyakarta using a Boeing 737–400, part of the second generation of the popular medium range airliner. In command of flight 200 on the morning of the 7th of March 2007 were two experienced 737 pilots: 44-year-old Captain Muhammad Marwoto Komar, a 21-year veteran of Garuda Indonesia, and 30-year-old First Officer Gagam Saman Rohmana, who had been flying with the airline for three years. Joining them on board the early morning flight were five flight attendants and 133 passengers, including numerous Indonesians as well as a group of Australian officials and journalists attending a meeting between the Australian and Indonesian foreign ministers in Yogyakarta.
At 6:00 a.m. local time, flight 200 took off from Jakarta for the approximately one hour hop to Yogyakarta. Throughout the climb and cruise phase, the flight was entirely routine, and as the plane neared its destination, Captain Komar gave a perfectly normal approach briefing, telling First Officer Rohmana that they would land on runway 9 using the instrument landing system (ILS), with a target airspeed of 141 knots (261km/h), flaps extended to 40 degrees, and a decision height of 587 feet.
Twelve minutes later, the approach controller in Yogyakarta cleared flight 200 to perform a visual approach to runway 9. But Captain Komar had not briefed the procedures for a visual approach, because he had planned to use the ILS. Instead of changing plans or asking the controller for a new clearance, he simply went ahead with the ILS approach, which he did not have permission to perform.
To complete the ILS approach, they needed to intercept the signal from the glide slope, which would guide the plane down at the correct angle to reach the runway. But right off the bat, there was a problem: flight 200 was coming in too high, and would need to enter a steep descent in order to reach the glide slope. Paying close attention to his altitude, Komar pitched the plane down and began to descend.
At 6:51, flight 200 descended below 10,000 feet, still well above the glide slope. As Komar kept the nose pointed steeply downward, the plane’s speed began to increase, exceeding the speed limit of 250 knots (463km/h) imposed below 10,000 feet. And over the next several minutes, their speed only continued to increase, reaching 269 knots (498km/h) by 6:54. Still, in the cockpit everything seemed relaxed. Captain Komar quietly sang to himself and occasionally exchanged superfluous remarks with First Officer Rohmana, in violation of the sterile cockpit rule, which prohibited non-pertinent conversation at low altitudes. In the perfect morning weather, they easily spotted the runway, informed the approach controller that they had visual contact with the airfield, and received clearance to descend to 2,500 feet.
But still, they were above the glide slope, and Komar was becoming increasingly worried that he wouldn’t be able to reach it in time. He steepened the descent even more, and by the time the plane had descended to 3,400 feet above the ground, they were traveling at an unbelievable 293 knots (543km/h), or 337 miles per hour, a speed more reminiscent of the cruise phase than the descent to the airport. And yet Captain Komar seemed to have no idea how fast they were going.
Despite not looking at his airspeed indicator, it would have been hard not to notice such an extreme speed, and Komar pulled back a little bit to 243.5 knots (451km.h) over the next minute. He instructed Rohmana to extend the flaps to one degree, and then two, to help them slow down and increase lift for a smooth landing. Normally, the flaps must be extended to 30 or 40 degrees for landing, but Komar had by now decided that the only way to get to the runway would be with the flaps at 15 degrees, allowing them to descend more steeply than flaps 30 or 40. It didn’t occur to him that if they couldn’t reach the glide slope using the normal flap settings, it might be better to go around and try the approach again.
At 6:56, Captain Komar called out “gear down,” and First Officer Rohmana lowered the landing gear. One minute later, still traveling at 238 knots — more than 100 knots over the normal landing speed — Komar said to Rohmana, “Check speed, flaps 15.” But upon checking their speed, Rohmana saw that they were far above the maximum speed of 205 knots for that flap setting; in fact, extending the flaps to 15 degrees while so far above the maximum could cause damage to the flaps or even rip them right off the plane. Instead, he extended the flaps to only 5 degrees, which was the most he could command at that speed. “Flaps five,” he replied, without explaining why he couldn’t extend them to fifteen. Why he thought Komar would be able to understand the problem based on such an ambiguous reply is unclear.
By now the plane was dropping at a terrifying 3,460 feet per minute, more than three times the maximum descent rate allowed on approach, and enough to destroy the plane on touchdown. To many of the passengers, it was obvious that something was wrong; some even predicted that they were going to crash and assumed the brace position. In the cockpit, the Enhanced Ground Proximity Warning System (EGPWS) detected a dangerous closure rate with the ground and began to emit a series of dire warnings.
“SINK RATE,” it said, warning that they were descending too quickly. Captain Komar ignored it.
“TOO LOW, TERRAIN!” the robotic voice called out. “TOO LOW, TERRAIN!”
The plane reached a height of 1,000 feet above the ground, the point at which the approach must be stabilized in order to continue the landing. Flight 200’s approach was unstable in almost every possible way: they were too fast, they were above the glide slope, they weren’t configured for the landing, and their sink rate was too high. But Komar kept right on going, plowing onward toward the airport below, as though his world had shrunk down to nothing more than his yoke and the runway.
Seconds later, the controller cleared flight 200 to land, and Komar again said, “Check speed, flaps 15.”
First Officer Rohmana said nothing. The EGPWS blared, “TOO LOW, TERRAIN!”
“Check speed, flaps 15,” Komar said again. There was no response. “Flaps 15,” he said. “Flaps 15! Check speed, flaps 15!”
“WHOOP WHOOP, PULL UP!” screamed the EGPWS. “WHOOP WHOOP, PULL UP!”
“Wah, Captain, go around, Captain!” said the terrified first officer.
Captain Komar ignored him. “Landing checklist completed, right?” he asked.
Utterly bewildered, First Officer Rohmana couldn’t formulate a reply.
Flight 200 overflew the runway threshold at twice the normal height and 98 knots above the normal landing speed. Captain Komar pulled back to flare, the plane leveled momentarily, and then he slammed it onto the runway 860 meters beyond the normal touchdown point and 87 knots too fast.
“Go around!!” Rohmana screamed. The plane hit the runway so hard that it pulled nearly 2 G’s and bounced into the air, prompting Captain Komar to plant it nose-first back into the ground.
The second impact sent the plane airborne again, before it finally touched down a third time with enough force to destroy both front wheels and collapse the nose gear. Throwing up sparks as the cockpit slid along the runway, the plane careened toward the edge of the airport, unable to stop despite Komar’s attempts to hit the brakes and activate the thrust reversers. The 737 ran through the runway end safety area and over the grass, broke down the airport perimeter fence, struck a ditch, crossed a road, hit another ditch and an embankment, and plowed several dozen meters into a rice paddy. The impact bent the cockpit backward and partially beneath the main passenger cabin, while the right wing ripped off, swung up and over the fuselage, and crashed to earth on top of the left wing. Both engines separated and rolled along behind the plane before coming to a halt in the muddy field. Jet fuel, liberated from the tanks in the right wing, sprayed all the way down the right side of the fuselage and immediately ignited.
On board the plane, almost everyone had survived the violent crash, although many had suffered injuries ranging from lacerations to broken bones to concussions. As flames erupted right outside their windows, dazed passengers rushed toward the exits, throwing open the doors and jumping down into the knee-deep water that surrounded the plane. Bleeding and limping, they staggered away from the burning plane, staring back in disbelief as towering flames and billowing smoke poured from the shattered fuselage. News cameraman Wayan Sukardo, who survived the crash, soon turned his video camera back toward the plane, capturing the long lines of dazed passengers walking away through the rice field. But not everyone had escaped: inside the plane, smoke rolled down the aisles and plunged the cabin into darkness, as the raging fire began to shatter the windows and spread into the fuselage. People pushed and shoved against each other in total darkness, some managing to find the exits and collapse through the open doors, but others perished in the smoke and flames.
Meanwhile, the airport’s fire services rushed to the scene, but found that they couldn’t get their trucks near the plane due to the ditches, fences, and berms surrounding the rice paddy. The water cannons couldn’t reach the plane, and extinguishing hoses were quickly run over by vehicles and punctured. To make matters worse, there was no clear on-scene commander, and several different people began to issue their own orders, some of which were contradictory. As the first responders struggled to figure out what to do, the plane burned out of control and the surviving passengers began to tend to each other’s injuries, until paramedics managed to maneuver their stretchers over the fences and into the rice paddy to render assistance.
Although initial death counts reported in the media varied considerably, it was eventually concluded that 21 people had died inside the burning plane, including a flight attendant. Among the dead were several support staff and journalists who had been part of the Australian delegation to the diplomatic summit in Yogkyakarta (although the two foreign ministers were on a different plane). A further 112 people were injured, 12 of them seriously.
This was hardly the first time that Garuda Indonesia was involved in a major accident. Between 1975 and 2007, Garuda had suffered no less than seven other fatal crashes resulting in a total of 374 fatalities, including a 1997 accident in which 234 people were killed. The airline also suffered constant incidents and near misses such as runway overruns and landing gear collapses. Among the world’s flag carriers, Garuda Indonesia was considered one of the worst in terms of safety. The crash also came less than three months after Adam Air flight 574 crashed during a flight between the Indonesian cities of Surabaya and Manado, killing all 102 people on board. Indonesia’s rate of fatal crashes per million takeoffs was fifteen times the global average. As investigators from Indonesia, the United States, and Australia began work to uncover the cause, European regulators decided that they had seen enough. In the summer of 2007, the European Union banned all Indonesian airlines from flying to Europe, scuttling Garuda Indonesia’s plans to add flights to European destinations beginning in 2008.
Meanwhile, investigators recovered the black boxes and examined their contents in Canberra, Australia. Both proved to be shocking. The flight data recorder showed that flight 200 had landed at a speed 87 knots (161km/h) faster than normal, and at a point 860 meters beyond the touchdown zone, easily explaining why the plane ran off the end of the runway. The speed and angle of the final touchdown also exceeded the structural limits of the nose gear, causing it to collapse.
To understand why the plane landed so hard and fast, investigators reviewed the cockpit voice recording. Its contents were utterly bewildering. Captain Komar appeared to have deliberately flown an approach that far exceeded the normal limits on speed and descent rate, landed with only 5 degrees of flap, and ignored no less than 15 EGPWS callouts, the most serious type of warning that a pilot can encounter. First Officer Rohmana called for a go around twice, but his cries went unheeded. Investigators described it as some of the worst cockpit conduct they had ever seen.
Interviews with Captain Komar revealed that at the very least, the crash wasn’t deliberate. He remembered hearing the EGPWS warnings but believed he could land anyway. He didn’t know what his airspeed was at any point during the descent, and every decision was made in order to allow him to reach the runway, seemingly without regard for whether this was reasonable. Furthermore, on the cockpit voice recording he asked for “flaps fifteen” four separate times, as though his thought process was stuck on that particular item, and when First Officer Rohmana first called for a go-around, Komar instead asked whether the landing checklist had been completed. All of these behaviors were symptomatic of a psychological phenomenon called fixation. Somehow, Captain Komar had fallen into a narrow mindset in which he became singularly fixated on the goal of getting the plane on the runway, to the point that his brain simply disregarded any information other than their position relative to the glide slope and what he needed to do to get on course. Any cues suggesting that this goal was impossible and that the plan was best abandoned were simply tuned out. Unfortunately, a safe landing really was impossible: despite its breakneck descent, flight 200 never managed to capture the glide slope.
To understand how a pilot could succumb to a psychological trap that he should have known how to recognize, investigators turned to the pilots’ training. They found several disturbing shortcomings. Neither pilot had ever been checked on his ability to respond correctly to EGPWS alerts, and multiple instructors had noted that Captain Komar tended to fly approaches too fast. Most disturbingly, investigators discovered that shortly before the accident Garuda Indonesia had introduced a policy whereby pilots would be rewarded for using less fuel, which could have incentivized continuing the approach instead of going around. However, Captain Komar turned down this opportunity to throw his airline under the bus and told investigators that the fuel policy did not in any way influence his decision making. Nevertheless, it was suggestive of a company culture where cost savings were considered more important than safety.
The inquiry into the pilots’ training also shed some light on why First Officer Rohmana, despite his abject horror at the actions of his captain, never took control: although Garuda’s company rules required the first officer to step in and fly the plane if the captain is compromising the safety of the flight, neither Rohmana nor any other first officer was evaluated on his ability to recognize when this was appropriate and respond effectively. His failure to explain why he couldn’t extend the flaps past 5 degrees also seemed to point to an atmosphere in which first officers were not encouraged to speak up.
Unsurprisingly, a regulatory audit of Garuda Indonesia conducted in 2001 had found widespread crew coordination problems as a result of these training issues. Captains habitually ignored their first officers, situational awareness and decision making were extremely weak, and unstable approaches were routinely continued to landing. Considering that pilots did not seem to place much weight on the concept of a stable approach, the opinions of first officers were not valued, and Komar was used to exceeding normal approach speeds, the sequence of events on board Garuda Indonesia flight 200 began to make more sense.
Underpinning this poor pilot training was a lack of regulatory oversight. Indonesia’s Directorate General of Civil Aviation (DGCA), the equivalent of the US Federal Aviation Administration, was supposed to ensure that all Indonesian airlines complied with regulations. But the weak and understaffed agency had only audited Garuda Indonesia once in the entire decade leading up to the crash, which was obviously insufficient to detect recurring patterns of regulatory non-compliance in pilot training that plagued the airline. It was apparent that Indonesia’s safety problems came not so much due to a lack of regulation — although there were gaps in some areas — but due to the almost complete absence of any enforcement mechanism. This was the deficiency that led not only to Garuda Indonesia flight 200, but also contributed to all the other transportation accidents that rocked Indonesia on an almost monthly basis.
Finally, the investigators revealed major problems with the design of the airport and its emergency response procedures that contributed to the deaths of 21 people in what should have been a survivable crash. Key to the outcome was the fact that the plane came to rest in a rice paddy surrounded by ditches and fences that prevented fire trucks from reaching the crash site until after the fire had already consumed the plane. These same obstacles also hindered the ability of paramedics to reach the injured passengers. Airport authorities did not seem to have considered what would happen if a plane ran off the end of runway 9, even though this result should have been eminently foreseeable, especially considering that the runway end safety area was shorter than the minimum specified by the International Civil Aviation Organization. Furthermore, airport firefighters had not been trained in any scenarios in which a crash occurred outside the airport perimeter fence; they had not conducted any training simulations since 2005; and firefighters complained that the simulations they did conduct were unrealistic. All of these factors left them unprepared to respond to a real accident.
In October of 2007, Indonesia’s National Transportation Safety Committee (NTSC) released its final report, which stated that causes of the crash were excessive speed and descent rate, poor crew communication, disregard for the 15 EGPWS alerts, the captain’s failure to abort the approach, and the first officer’s failure to take control and perform a go around. The details of the events on board the flight shocked the world: how could a supposedly trained and experienced pilot fly so recklessly when the lives of passengers were in his hands?
After the publication of the report, the Australian government called on its counterpart in Indonesia to press charges against Captain Komar, over the protests of their own accident investigation team, and Indonesia complied. On the 5th of February 2008, Komar was arrested on charges of manslaughter, and although the Indonesian government attempted to argue that there was risk of him fleeing the country, he was subsequently released on bail. Komar did not flee the country; instead, he and his lawyers denounced the charges and vowed to defeat them in court.
The case for the manslaughter charges, which could land Komar in jail for five years, was fairly strong. But at the same time, many legal experts and air crash investigators expressed alarm at the decision. According to Annex 13 of the International Civil Aviation Regulations, the agreement under which most accident investigations are conducted, the contents of an aircraft’s black boxes, as well as interviews with crewmembers as part of the investigation, must not be used for any purpose other than finding the cause of the accident. There is in effect a tacit agreement between pilots, airlines, and investigators that testimony given to an accident investigation — whether it’s in post-crash interviews or recorded on the CVR — will not be used against any individual in court, unless the benefits of doing so outweigh the sanctity of the agreement. When asked about this dilemma, Australian Foreign Minister Alexander Downer replied, “I think our first priority is to make sure those who are responsible — who survived the accident — are brought to justice.” Instead of confronting the uncomfortable controversy surrounding the decision, he simply dodged the question.
On the surface, it seems appealing to try Captain Komar for manslaughter. His actions during the flight directly led to the deaths of 21 people, while he walked away unhurt — the sort of poetic injustice that makes our blood boil. Such a situation evokes a primal desire for revenge that is often mistaken for a desire for justice.
But a more detailed examination reveals why charging a pilot with manslaughter after an accident like Garuda Indonesia flight 200 is not only wrong, but dangerous. By undermining the promise that statements given to the investigation will not be used in court, it makes it harder for future investigations to get critical information from witnesses who may be at fault in the accident. If a pilot fears criminal prosecution for revealing the truth, the goal of finding the cause of the accident will be sidelined. The result is that safety suffers.
There is also an ethical consideration to be made. The purpose of a prison sentence is — or at least should be — to isolate a dangerous criminal so that he or she cannot harm others. A thief or a murderer is locked away so that they cannot steal or kill again. But what about a pilot who flew too fast on approach and overran the runway? Captain Komar didn’t go to work that morning intending to crash a plane and kill 21 people. Furthermore, he was fired from Garuda Indonesia and there was no chance he would ever fly an airliner again. So what was the point of putting him in jail? Certainly it wasn’t to keep others safe. Sentencing a pilot like Komar to prison is more akin to the fulfilment of a popular revenge fantasy — no benefit is gained by locking him up, except that we feel good for having done so. Politicians who should know better call for gratuitous punishments because the public demands it.
On the 6th of April 2009, Captain Muhammad Marwoto Komar was sentenced to two years in prison for criminal negligence. His lawyers vowed to appeal, and the Garuda pilots’ union threatened to go on strike unless the conviction was overturned. “Our main concern is that this decision could actually disturb aviation safety,” said union chief Stephanus Gerrardus. “Imagine how hard it would be for a pilot to perform his duty when he’s burdened with something like this. It makes pilots doubtful, and could lead to mistakes. If we don’t get any… correction on this, we will not hesitate to strike.” The Indonesian Pilots Federation, which represents other Indonesian pilots, also stated that it would consider striking if the conviction was upheld on appeal. In the end, the unions got their way: on December 12th, an appellate court overturned the lower court’s decision, ruling that prosecutors had failed to prove that a crime was committed. After a two year ordeal, Captain Komar finally walked free.
While lawyers were battling over whether Komar had committed a crime, regulators and investigators worked to begin the herculean task of improving Indonesia’s dismal safety record. In its final report, the NTSC issued a long list of recommendations, including that Garuda reconsider its fuel incentive program; that all Indonesian pilots be evaluated on their ability to respond to EGPWS warnings; that Indonesian airlines make use of the Flight Safety Foundation’s training modules on approach/landing and controlled flight into terrain accidents; that the DGCA step up its inspections of Indonesian airlines in order to fulfil its legal mandate; that Yogyakarta Airport extend the runway overrun areas to meet the minimums specified by ICAO; that Indonesian airports ensure their firefighting equipment meets minimum requirements, have plans for accidents occurring outside the airport perimeter, and establish clearly defined chains of command; and that the DGCA ensure airports near water or swamps have the appropriate types of rescue equipment. Prior to the publication of the report, Yogyakarta’s Adisujipto International Airport constructed an access road to allow vehicles to enter the rice paddy and updated its firefighting equipment; and Garuda Indonesia emphasized to pilots that they will not be punished for performing go-arounds, and implemented new EGPWS training.
Following the publication of the report, Garuda Indonesia began a complete restructuring of its safety regime, from training to flight operations to maintenance. The crash and the ban on flights to Europe proved to be the wake-up call that the troubled airline needed; its management finally seemed to realize that they were the face Indonesia presented to the world, and that they had to start acting like it. Over the years following the crash, Garuda was completely transformed, and in June 2009, the ban was lifted. Shortly thereafter, Garuda Indonesia inaugurated a flight from Jakarta to Amsterdam as a celebration of its progress. The efforts seem to have paid off: today, Garuda Indonesia is considered a safer than average airline, and flight 200 was its last fatal accident. The same cannot be said for Indonesia’s domestic carriers, however. The country continues to suffer a fatal accident every couple of years, usually involving sketchy low cost airlines that still lack adequate oversight. But the progress made at Garuda shows that change is possible — instead of simply sending a pilot to prison and declaring their mission accomplished, experts tackled the real root cause of the problem, in the process making Indonesia a safer place to fly.
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