Wednesday, March 12, 2008

A Garuda B737-400, comparable to the one involved in the disaster.Image: Terence Ong.

Almost exactly one year ago, on March 7, Garuda Indonesia Flight 200 crashed during landing at Adisucipto International Airport, near Yogyakarta, after a scheduled domestic Indonesian passenger flight. 21 people – 16 Indonesians and five Australians – were killed when the Boeing 737-400 overshot the runway, crossed a road, struck an embankment and burst into flames in a rice paddy. Overall, the plane had traveled 252m beyond the extreme end of the runway.

The final report, released in October, blamed pilot error for the disaster. The report stated that the aircraft had approached at a speed far exceeding that at which the wing flaps could properly operate, and attempted to execute a landing at 408 kph (254 mph), which is 160 kph (100 mph) above the safe speed. It also found that captain Marwoto Komar had ignored fifteen activations of the Ground Proximity Warning System (GPWS) informing Mr Komar that the aircraft was flying at a speed beyond that at which it could safely land, but he failed to abort.

It also commented that he missed one further opportunity for emergency evasive action when the airliner struck the runway and bounced into the air, at which point co-pilot Gagam Rochmana requested a ‘go-around‘ procedure be initiated, but was also ignored. It further criticised Mr Komar for singing during final approach, a direct violation of the Garuda Basic Operations Manual, which calls for activation of the Sterile Cockpit Rule at 10,000 feet and below.

Mr Rochmana was also criticised for his failure to take control away from Mr Komar when it became apparent that the aircraft was being operated in an unsafe manner. However, the report did note that Garuda Indonesia had failed to give him any simulator training replicating a situation whereby the co-pilot would take over control duties from the pilot in charge due to unsafe handling of the plane; in fact, training was found to be inadequate for both members of the cockpit crew.

Further criticisms were also leveled at airport and governmental authorities for failures in their respective roles to provide safety features and to enforce regulations.

Illustration of a typical go-around procedure. Note that the actual incident differs because the aircraft had bounced off the runway prior to the call for a go-around.

However, the Indonesian authorities have recently generated intense controversy by deciding to prosecute Mr Komar for his role in the disaster. The move has been pushed for by some, but met with opposition by others.

Alexander Downer, Australian foreign minister at the time of the crash, immediately said “…I am very glad that they have reached a point now where they have charged the captain of the aircraft.” The unusually high number of Australians amongst the 140 passengers on board was attributable to a visit by Mr Downer.

One of those was Morgan Mellish of the Australian Financial Review, who died in the crash. His sister, Caroline Mellish, had specifically called for prosecution to be avoided, saying “I think having 21 deaths on your conscience is probably enough. I don’t think prosecuting the man is going to make any difference.”

There were fierce calls for prosecution of both pilots immediately after the report’s release, with Downer himself pressuring the Indonesian authorities, citing the “very credible report” and saying “I’ve asked our ambassador today (October 24) to make it absolutely clear to the Indonesians that we want people prosecuted for this accident. I want to see people who have negligently allowed Australians … to be killed, I want to see those people brought to justice.”

Australian Opposition Leader Kevin Rudd also made clear a desire for prosecutions, saying he had telephoned secretary-general of Indonesia’s foreign affairs department and former ambassador to Australia Imron Cotan, telling him that he wanted those responsible “prosecuted to the absolute full”. “This is a serious matter, many Australians visit Indonesia, Garuda is an often used airline and there is a basic national interest at stake here as well,” he said.

National Transport Safety Committee chairman Tatang Kurniadi said at the time that no information from the report could be used in any criminal or civil liability investigations. “I would like to go back to the objective of this, the report was made by NTSC for safety purposes only, not for blaming, he said. “If any institution wants to … follow up that accident, that’s their own decision. The report contained the results from the cockpit voice recorder and flight data recorder, but according to international regulations on aviation these black boxes are not allowed to be used for… liability purposes. We will not give police or any institution (information) other than for safety purposes only – it’s in international regulations and we want to follow those regulations.” He also confirmed that investigators cannot speak to the police, with the only permitted testimony under the legislation being to testify at a court hearing, and pointed out that the document does not actually appoint any blame.

The international legislation he was referring to is probably the Convention on International Civil Aviation, which stipulates that accident reports and related material, specifically transcripts of interviews, communications with crew and cockpit voice recorder and flight data recorder (collectively known as black boxes) readouts, must not be used for any purpose other than determining the cause of an accident or incident. The only possible exception to this is where potential benefit would outweigh the “adverse domestic and international impact” on the investigation in question or any other either in progress or in the future. This legislation is in place to provide protection to witnesses on the basis that without it they may be less likely to cooperate with investigational procedures.

The law caused was actively opposed by some. Aridono Sukman, the police member in charge of the criminal investigation, said that the contents of the black box were vital evidence. Officials commented that some relatives had expressed their frustration over the legal challenges involved in the prosecution effort.

Early in February Mr Komar was arrested; he has subsequently been charged with manslaughter charges which carry a maximum sentence of five years’ imprisonment. The London-based International Federation of Air Line Pilots Associations (IFALPA) issued a press release condemning this move, saying that further investigations are needed into the crash, and that criminal proceedings could prevent an accurate version of events from ever being known. Specifically, the release said that “IFALPA believes that the circumstances of the accident as set forth in the final report of the Indonesian investigation authority leaves many serious questions concerning the crew actions prior to the accident. Central to these concerns are the underlying reasons for the reported behavior of Captain Marwoto Komar. Experienced pilots have considerable difficulty in attempting to explain what is reported in the context of normal airline operations. The Federation believes that the explanations proffered by the report do not square with the collective experience of our members.” The release went on to state the opinion that prosecution may bring total foreclosure to the case and could only be counterproductive. It also said “He remains a professional who was involved in an unfortunate tragedy.”

One possible explanation had previously been suggested by the head of the Garuda pilots association, Stephanus Geraldus. He said that marital problems between Mr Komar and his wife Norma Andriani were “common knowledge” and was backed up by an industry analyst and pilot who said he believed the couple had been arguing late into the night, and expressed concern that the report had not addressed psychological issues. Mr Geraldus also said sleep deprivation could have contributed, with the flight crew reporting for duty at 4:30 am and the flight departing an hour and a half later.

The report had hinted at problems, saying The pilot was probably emotionally aroused because his conscious awareness moved from the relaxed mode “singing” to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilised approach,” and “His attention was fixated or channelised on landing the aircraft on the runway and he either did not hear, or disregarded the GPWS alerts, and warnings, and calls from the copilot to go around.” It is also known that Mr Komar had been under police surveillance, during which time he was receiving psychological treatment.

The Indonesian Pilot’s Association has also said that the criminal prosecution should be avoided, arguing that the only people who can judge whether mistakes were made in aviation are those professionally involved and not the police. There were protests in Jakarta demanding his release and dozens of pilots across the nation also campaigned. Meanwhile, two survivors, Adrianus Meliala and Retno Gunowati, went to the House of Representatives (DPR) to challenge those opposed to legal processes against the pilot.

Mr Komar was released on police bail on February 15, and is currently awaiting trial. He was forced to resign late in February with being fired his only alternative, and his licence has been suspended. He is believed to be the only man ever prosecuted in Indonesian history over an airliner crash.

The issues thrown up by this ongoing case have now been exclusively commented on for Wikinews by Paul McCarthy. Mr McCarthy is IFALPA’s representative to the International Civil Aviation Organisation (ICAO). He is both a pilot – as are all of IFALPA’s roughly 100,000 members – and a lawyer, and is an acknowledged expert on issues concerning the criminal liability of pilots. Mr McCarthy’s comments, obtained by email via IFALPA media representative Gideon Ewers are available below.

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