Garuda Indonesia Flight 152

Garuda Indonesia Flight 152

A Garuda Indonesia Airbus A300 registered PK-GAG, similar to the aircraft involved in the accident.
Accident
Date	September 26, 1997
Summary	Controlled flight into terrain due to ATC error, pilot error, and GPWS malfunction
Site	Near Pancur Batu, Deli Serdang, North Sumatra, Indonesia 03°15′53″N 098°40′48″E / 3.26472°N 98.68000°E / 3.26472; 98.68000Coordinates: 03°15′53″N 098°40′48″E / 3.26472°N 98.68000°E / 3.26472; 98.68000
Aircraft
Aircraft type	Airbus A300B4-220
IATA flight No.	GA152
ICAO flight No.	GIA152
Call sign	INDONESIA 152
Registration	PK-GAI
Flight origin	Soekarno-Hatta Int'l Airport, Jakarta, Indonesia
Destination	Polonia International Airport, Medan, North Sumatra, Indonesia
Occupants	234
Passengers	222
Crew	12
Fatalities	234
Survivors	0

Garuda Indonesia Flight 152 was a scheduled domestic Indonesian passenger flight from Soekarno-Hatta International Airport in Jakarta to Polonia International Airport in Medan, North Sumatra, operated by Garuda Indonesia using an Airbus A300B4 registered PK-GAI.

On September 26, 1997, Flight 152, on final approach into Polonia International Airport, crashed into mountainous woodlands 30 miles (48 km) from Medan during low visibility caused by the 1997 Southeast Asian haze. All 234 passengers and crew were killed in the disaster. The crash site was in a ravine near the village of Buah Nabar in the Sibolangit district south of Medan.^[1]

Aircraft

The Flight Deck of an A300B4 with the FFCC conversion. While modified for two crew operation, the FFCC does not have the electronic instrumentation of the A300-600 model.

The aircraft was an Airbus A300B4 FFCC, or "forward-facing crew concept." The standard A300B4 requires two pilots and a flight engineer, and is configured with a control station mounted on the right side wall of the flight deck behind the pilots. The FFCC model is a modified version in which the flight engineer station is eliminated, and the relevant controls are simplified and relocated to be positioned on the ceiling between the two pilots. This control arrangement is similar to the Airbus A310 series, the difference being that with the exception of the autopilot (also borrowed from the A310), the FFCC retains the analogue flight instrumentation of the original A300. The FFCC would later be developed into the A300-600 series, in which all elements of the flight deck are brought to A310 standards, including the addition of electronic flight instrumentation. The two pilots aboard the accident flight were qualified to fly both the FFCC and the -600 model, however the adequacy of their conversion training between the two would later be called into question.

The Flight Deck of both the A300-600 and the A310 are quite similar to the A300B4 FFCC, however the navigation information is displayed digitally (note: this is an A310 flight deck that was photographed).

Accident

At approximately 1:00pm, air traffic controllers in Medan cleared Flight 152 for an ILS approach into Runway 05 from its current 316 degree heading, and the crew, led by Captain Rahmo Wiyogo, 42, a pilot with over 20 years of flying experience at Garuda Indonesia and more than 12,000 flying hours, and First Officer Tata Zuwaldi, a former flight engineer who recently upgraded to pilot, was instructed to turn left heading 240 degrees to intercept the ILS beacon. 120 seconds prior to impact, the crew was asked to turn left further, to 215 degrees, and descend to 2000 feet. At 1:30pm, Medan directed the flight to turn right heading to a heading of 046 to line up for arrival into Runway 05, and asked the crew to report which direction the plane was travelling. Air traffic controllers then became confused as to which plane they were talking to, as another flight, Merpati Nusantara Airlines Flight 241 was also in the area at the time.

It is worth noting that earlier in the day another Flight 152, Merpati Nusantara Airlines Flight 152, was handled by the same air traffic controller. This led to the controller mistakenly saying "Merpati one five two turn left heading 240 to intercept runway zero five from the right side"; as the wrong call sign was used, the Garuda pilots disregarded these instructions. The controller, on not receiving a response, queried the pilots on if they heard the instructions; this time the correct call sign "Indonesia 152" was used. The controller then repeated his instructions, though he did not say that the flight would be making its approach on the south side of the runway, or right side. The pilots believed they were flying the approach on the north side of the airport, as was the approach on the approach chart the pilots were using. Thus, when the pilots were instructed to turn right to a heading of 046 maintaining 2,000 ft to capture the localizer for the ILS to Runway 05, out of habit – or possibly due to the approach chart – the captain initiated a left turn to a heading of 046. The First Officer was distracted during the turn and did not notice for a while that the aircraft was turning left. When he did notice, he told the captain he was turning the wrong way, and the captain questioned the controller over which way they needed to turn, to which the controller confirmed they were to turn right. A confusing conversation took place over which way to turn, with the controller not having a clear picture over what the flight was doing, due the Medan radar system having a refresh time of 12 seconds.

Without a constant up-to-date view over the flight's heading, the controller thought the plane was continuing left, when it was actually turning right and into high terrain. During this time the flight descended through 2,000 ft due to the captain inputting the wrong altitude of 1,500 ft. The pilots did not notice this due to the poor visibility from the 1997 Southeast Asian haze. Five seconds prior to the initial impact with trees, the First Officer made a comment about the airplane's altitude. The FDR recorded increases in pitch and engine power, likely commanded by the crew in an effort to correct their altitude. Shortly before the recording ended, the cockpit voice recorder registered the sound of the plane striking trees, followed by shouting from the pilots. The aircraft crashed into the ground at 1:34 pm, killing all 234 people on board.

Nationalities

The passengers were mostly Indonesian, but included two British, one French, four Germans, two Americans, two Canadians, one Italian, one Dutch, six Japanese, three Taiwanese, one Australian, one Belgian, one Malaysian, and one Swedish.^[2]

Nationalities of the passengers and crew

Nationality	Passengers	Crew	Total
Indonesia	198	12	210
Japan	6	0	6
Germany	4	0	4
Taiwan	3	0	3
Canada	2	0	2
United States	2	0	2
United Kingdom	2	0	2
France	1	0	1
Italy	1	0	1
Malaysia	1	0	1
Netherlands	1	0	1
Australia	1	0	1
Sweden	1	0	1
Belgium	1	0	1
Total	222	12	234

Investigation

The causes of the crash, according to the official report of the National Transportation Safety Committee (NTSC), were:

"There was confusion regarding turning direction of left turn instead of right turn at critical position during radar vectoring that reduced the flight crew’s vertical awareness while they were concentrating on the aircraft’s lateral changes. These caused the aircraft to continue descending below the assigned altitude of 2000 ft and hit treetops at 1550 ft above mean sea level."^[4]

The Report also criticized the airline's conversion training for pilots who fly both the A300-600 and A300B4-FF models. The former is equipped with digital navigation displays, while the latter is equipped with analog equipment. Though both are sufficient for conducting instrument approaches, the captain may have been overwhelmed due to his lack of familiarity with the analog instrumentation.^[5]

Contributing to the accident was the failure of the GPWS for undetermined reasons and the inadequate vectoring charts used by the controllers at Medan.^[6]

Lawsuits

The first lawsuit was filed by Nolan Law Group in Chicago, Illinois on September 24, 1998 on behalf of American passengers Fritz and Djoeminah Baden.^[7] Additional lawsuits were filed in state and federal courts in Chicago related to many more victims from Indonesia, Germany, England, Italy, and Australia. The sole defendant in the lawsuits was Sundstrand Corporation (later Hamilton Sundstrand Corporation), the company that designed and manufactured the Mark-II ground proximity warning system ("GPWS") installed on the Airbus 300. The plaintiffs alleged that the GPWS was defectively designed, that the manufacturer was aware of its deficiencies in mountainous terrain for over a decade, and had the system worked as designed the accident could have been avoided. Had the aircraft been fitted with EGPWS the crew would have had the alarm sound between 18 and 23 seconds before impact; the accident would have been avoided.

The victims' lawyers produced several internal memos from Hamilton-Sundstrand showing that the system had been inadequately tested for mountainous terrain, having been mostly tested on flat ground with gentle slopes. Perhaps the most critical memo was one written by Hamilton-Sundstrand engineer Donald Bateman, who wrote: "Based on recent flight demonstrations ... of the MK II GPWS, I have become very concerned about the Excessive Rate Detector Circuits in the MK II computers. I believe we have a much more potentially serious problem than was first envisioned in 1982. GPWS warnings can be short or non-existent in some circumstances." Bateman's memo went on to say that "the warning time for flight into mountainous terrain and steep descent rates from altitudes above the range of the radio altimeter can be very short and erratic at times ... From our studies, the average escape margin is only three-and-one-half seconds for the typical mountainous-terrain accident scenario." Sundstrand's in-house experts conducted their own after-crash simulations and confirmed that a properly functioning warning system should have sounded alarms about 14 seconds before impact and that the accident would have been avoided if that had occurred.

Nearly six years after the crash the lawsuit was settled out of court.^[8]

In Coyle v. P.T. Garuda Indonesia,^[9] Joyce Coyle filed a suit in the U.S. District Court for the District of Oregon against the Indonesian government subsidiary that operates Garuda Indonesia Airlines. Coyle alleged in her complaint that Garuda was liable for wrongful death under the Warsaw Convention. She also claimed that Garuda, which is wholly owned by the Indonesian government, could be held liable under two exceptions to the Foreign Sovereign Immunities Act. She contended that because Garuda was authorized to operate in the United States at the time, the immunity had been explicitly waived under the rules of the Department of Transportation, which requires foreign air carriers to open themselves to suit in the United States as a condition of being allowed to fly to, from, or within this country. The waiver is limited to actions arising under treaties. Coyle also claimed that by selling tickets in the United States, Garuda waived immunity under the "commercial activity" exception to the FSIA. U.S. District Judge Robert E. Jones denied Garuda’s motion to dismiss, adopting a magistrate judge’s conclusion that the trip to Medan was "one leg of an international journey" and thus subject to the Warsaw Convention and the explicit waiver of immunity.

On appeal to the U.S. Court of Appeals for the Ninth Circuit, Circuit Judge Diarmuid F. O’Scannlain, writing for a unanimous three-judge panel, rejected Garuda’s claim that a flight between two points in the same country will always fall outside the scope of the waiver. The Ninth Circuit still agreed with the defendant that under the circumstances, the Badens’ trip to Medan did not constitute "international air transportation" within the meaning of the Warsaw Convention. The facts that the tickets did not reference any international travel, were purchased in Indonesia from a source independent of the travel agent who sold them the U.S.-Indonesia tickets, and were labeled "DOMESTIK" unambiguously established that the flight was not part of their international journey as contemplated by the treaty, O’Scannlain said.

The court explained: "[T]he crux of this litigation is whether Flight 152 was a part of [the] larger international trip for purposes of the Warsaw Convention...whether it was a component of 'one undivided transportation...regarded by the parties as a single operation'...or just a late-added, purely domestic side trip apart from their international itinerary with its own final destination. The Badens' tickets for Flight 152 are powerful, unambiguous evidence of the latter."

Nor was the court persuaded by the "commercial activity" argument. For the exception to apply, O’Scannlain noted, the statute requires that the action arise from “a commercial activity carried on in the United States by the foreign state...or upon an act outside the territory of the United States in connection with a commercial activity of the foreign state elsewhere [when such] act causes a direct effect in the United States.” The fact that Garuda sold tickets in the United States did not furnish a sufficient nexus to subject its domestic flights to the exception, the judge wrote. Senior Judge Ferdinand F. Fernandez and Judge Raymond C. Fisher joined in the opinion.

Current Registration

Garuda Indonesia's fleet of ATR 72-600 aircraft use the same registration numbers as their previous fleet of Airbus A300, meaning that the registration PK-GAI was passed onto a currently-in-service ATR 72-600.

Dramatization

The crash of Garuda Indonesia Flight 152 is featured in the Fifth Episode on the Season 17 of Mayday (Air Crash Investigation). The episode is titled "Lethal Turn".

Aftermath

Garuda Indonesia still uses GA-152 flight number, but now used on Jakarta - Batam route operated by Boeing 737-800.

See also

• List of accidents and incidents involving commercial aircraft
• 1997 Southeast Asian haze
• 1997 Indonesian forest fires
• Alitalia Flight 404 another crash on approach where the GPWS didn't sound

Notes

External links

• AirDisaster.com accident file
• Pre-crash photos of PK-GAI