You are the commander of a Boeing 737 passing through
10,000' and setting up for a visual approach. You realize
that you have misjudged the wind and your descent
profile. You are likely to be too high and fast. You:
a) extend speed brakes
b) fly further out than usual before turning final
c) recheck your calulations
d) nose down and go faster, hoping it will work out
You are still high and fast. You call for flap 15 but
the co-pilot does not respond to your request. You:
a) ask him why he did not do as you asked
b) yell at him
c) extend them yourself
d) continue the approach without flaps
You are on final approach and the flaps are set to
five degrees extension. The manual calls for at least
thirty degrees of flaps for landing, but the manual also
calls for a much lower airspeed before extending that
much flap. You:
a) try to extend the flaps anyway
b) leave them up and land anyway
c) conduct a missed approach
You believe the flaps are malfunctioning, as you have
selected them down but the airplane is not slowing as it
usually does. You:
a) continue the approach at high speed
b) check all your power settings and other parameters
c) conduct a missed approach, extend the flaps at altitude and have a crew member go aft to the passenger cabin to confirm the position visually
You encounter windshear on approach to a runway.
a) conduct a missed approach in accordance to your company procedures
b) land with minimal flaps at above normal speed
c) continue at whatever speed and configuration you can attain, just to get the airplane on the ground.
You are at the position on the approach where your
company manual calls for you to be stabilized. You are so
high and so fast that the airplane automated systems
think you are crashing. You:
a) attempt to land
b) conduct a missed approach
You are almost a hundred feet above the runway
threshhold, well above landing speed and not in landing
configuration. The copilot is telling you to conduct a
missed approach, and does not confirm landing checks
a) attempt to land
b) conduct a missed approach
You touch down over a third of the way down the
runway, at well over maximum tire speed. The airplane
bounces twice, pulling almost three Gs, and the nose gear
collapses while the copilot yells at you to go around.
One of the engines comes off its pylon. You:
a) kill 22 people and injure almost everyone else.
Sadly, there is only one choice in the end, and that is the adventure a real life commander chose.
Indonesian pilot Marwoto Komar has been sentenced to two years in jail after being found guilty of criminal negligence for attempting to land a Boeing 737 in the wrong configurations and at almost twice the normal speed. The jet overran the end of the runway into a rice field. Twenty-two people were killed and fifty were seriously injured in the crash and ensuing fire. The Daily Telegraph story here includes a dramatic photo of the post crash fire.
According to the investigation report, the aircraft was already fast through 10,000' on the approach, as they exceeded the crew accepted a straight in visual approach to Yogyakarta but continued on the ILS approach without informing ATC. As long as someone is looking out the window, there's not a lot of difference between a well-flown long straight in visual and an ILS approach, but unfortunately this was neither. The aircraft arrived overhead the initial approach fix high and fast. Not just a little bit high, but at 3927' instead of 2500'. It wouldn't be the first time a crew had cut a few corners and come in too high, but the captain, who was the pilot flying, elected to rectify the situation by lowering the nose into a steep descent. There's an expression in aviation: you can go down or slow down. They had been trying to do both for the whole descent, at one point reaching 293 knots below 10,000', knowing they had a tailwind.
The captain called for more flaps, but the first officer did not extend them because the airspeed was 33 knots over flap extension speed. The captain continued to ask for flap fifteen right through the approach, but the FO never extended them nor gave a reason why he was not doing so. The ground proximity warning system reacted to the configuration, speed and rate of descent by issuing alerts and warnings, which the crew ignored, fifteen times.
They arrived over the beginning of the runway still 89 feet in the air and travelling at 232 kts with flap 5 (as opposed to the manufacturer's recommended 134 kts with flap 40). The aircraft touched down 860 m from the threshhold (more than a third of the way along the runway), bounced twice, then landed again still well over the recommended tire speed. The nosewheel tire burst, sending up sparks as what was left of the gear scraped along the runway. Both thrust reversers were deployed, and presumably the brakes were applied, but with too much speed and too little runway remaining, the overrun was inevitable.
It does not appear that there were any mitigating issues such as approaching weather, critical fuel, or pre-existing emergency.
There are so many issues here. I'll touch responsibility, training, co-pilot assertiveness and the role of the criminal justice sytem in air safety.
The captain never took responsibility for the crash. "Lack of remorse" was even cited as a factor in his sentencing. Compare to Captains Sullenberger and Haynes who saved lives landing airplanes crippled by circumstances beyond their control, but later agonized over what they could have done better. It's almost bizarre how Komar blamed everyone and everything but himself. He attended the trial in uniform, and fully expected to return to work.
He claimed windshear at touchdown. It's a known problem in the area and something a captain with over 13,000 hours of experience should be able to recognize, but there were no other reports of windshear in the area, no indication that it might be present from the detailed winds aloft, and a professional approach marred by windshear is inconsistent with the speed profile recorded throughout the descent.
He claimed that the flaps were faulty and did not extend when selected, but investigation found "no evidence of any defect or malfunction with the aircraft or its systems that could have contributed to the accident." The chief crash investigator, Mardjono Siswosuwarno, said the aircraft's wing flaps failed to extend for landing and that might have been caused by the high speed, but that's not something the captain can blame on the flaps.
The captain also levelled blame at the co-pilot, for not lowering the flaps, and at the poor emergency services. Admittedly the copilot did not clearly refuse the flap extension command by stating "Unable, we're thirty knots high" or whatever his SOP callout was, and the emergency services at the field were poor and contributed to the death toll, but none of that excuses the captain's actions.
The PIC said that he was unaware of the actual airspeed and expected that the copilot would inform him of any speed concerns, but that doesn't align with the comments he made during the descent, or the knowledge that someone with 3700 hours on the airplane would have to possess. The copilot called for a go around before and after touchdown, and the captain did not respond. It has been suggested, (but the captain has denied) that a company incentive to save fuel led to the decision to continue the unstable approach.
Poor training probably contributes to the decisions the crew made. For example, training records showed that the pilots had attended an "introductory" GPWS course with no evidence of related sim training. Non-pilot staff seem to be lacking some basic training in public relations, seeing as they got took their pictures taken, smiling, with the burned out wreckage. But how much training does it take to choose a missed approach at some point in that accident sequence? The copilot doesn't seem to have had sim training in the actions he needed to take in order to take control of the airplane from a captain who has not stabilized the approach. He did try. He said, he had shouted at the captain to go around because "that was the proper procedure ... to ask people to go around with yelling".
And that's tough. You need training, confidence and a company culture that will support taking an airplane away from a captain. This co-pilot stuck up for the captain after the crash. I don't believe that he literally blacked out from the g-forces. I think he needs a story to tell himself to explain why he did not take control and perform the missed approach. It reminds me of Michael Origel, the co-pilot of American Airlines flight 1420 that overran the runway in Little Rock Arkansas during a landing in a thunderstorm. Origel insists that he called for a go around, despite the fact that experts can find no trace of it on the CVR. I believe him. The voice in his head screaming that this was not right was so loud that he can't believe the captain and the recording microphone didn't pick it up. Has there ever been an accident in which a copilot's loud demands that a captain go-around were cited as a cause or contributing factor? Ever hear of a copilot fired for asking a captain to go around? I can name names, hell I have a pocket in my formal coat containing funeral programmes that name names of people who might be alive today had they demanded a go around.
But considering all the things that people did or didn't do, should or shouldn't have known to do, was a criminal act committed? They broke company policy in the lack of a stabilized approach, but I don't know that they broke air regulations. Could the possibility of the CVR being introduced as testimony in court cause pilots not to admit errors in flight?
It is very uncommon for a pilot to be charged with a crime in connection with a crash. It's a somewhat disturbing precedent when you're a pilot. We're usually assumed to be doing what we believe is best for the flight, in defense our own necks, and air law gives us a lot of latitude to do things that would otherwise be against the rules to defend our safety. Any misjudgements we make already force us to face possible injury or death and then we have to defend them to our own conscience, our boss, and the aviation regulatory authority. Do we need to add the civil justice system?
The decisions the captain made during this flight seem reckless. I think his conviction is closer to the correct outcome than having the manufacturer sued for the flaps failing to deploy at excessibe speeds, but I'm not convinced that the justice system should have a role here.