Garuda Indonesia Flight 152

Garuda Indonesia Flight 152

A Garuda Indonesia Airbus A300 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
Aircraft
Aircraft type	Airbus A300B4-220
Operator	Garuda Indonesia
Registration	PK-GAI
Flight origin	Soekarno-Hatta Int'l Airport, Jakarta, Indonesia
Destination	Polonia International Airport, Medan, North Sumatra, Indonesia
Passengers	222
Crew	12
Fatalities	234 (all)
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.

Flight 152 remains the deadliest single-plane crash in Indonesia, and the deadliest aviation accident in 1997.

Accident

At approximately 1:00pm, air traffic controllers in Medan cleared flight 152 for an ILS approach into Runway 5 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 5, 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 also worth noting that earlier in the day a Merpati Nusantara Airlines Flight 152 was handled by same air traffic controller, this confusion led to the pilots not hearing the first call, in which the controller said "Merpati one five two turn left heading 240 to intercept runway zero five from the right side", as the wrong callsign was used the pilots were not listening to these instructions. the controller on not receiving a response queried the pilots on if they heard the instructions, from this time with the correct callsign "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 5, 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 flights heading thought the plane was continuing left, when he was actually turning right and into high terrain, during this time the flight descended through 2,000 feet 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. The pilots saw the mountain and tried to climb over the trees but did not have enough time, the Airbus A300 then hit trees and crashed into high terrain 45 km from the Runway 05 threshold, 18 km to the south of the center line. The aircraft hit the ground right wing low, turning towards the airport though at a heading of 311 degrees at an altitude of 1,510 ft MSL. All 234 people on board died.

Passengers

The passengers were mostly Indonesian, but included two British, one French, four Germans, two Americans, two Quebec Canadians, one Italian, one Dutch, six Japanese, three Taiwanese, one Australian and one Malaysian.

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
Total	222	12	234

Passenger remains

Forty-eight of the bodies recovered from the crash were too mutilated to be identified and were buried in a mass grave in a cemetery outside Medan's Polonia Airport, where 61 victims of the 1979 Garuda Fokker F28 crash were also buried. The remaining 186 bodies were identified and returned to their families for private burial.

Investigation

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

1. The aircraft turned left instead of right as instructed by the ATC due to pilot error on the part of the Captain.
2. The aircraft descended below the assigned altitude of 2,000 feet (610 m) and thereafter struck treetops at 1,550 feet (472 m) above mean sea level.

Transcript of final communication

The following transcript is an unofficial extract of the air traffic control (ATC) communications as appeared in the press.

• MNA 241 is Merpati Flight 241 (approaching)
• BOU 683 is Bouraq Flight 683 (departing)
• GIA 152 is Garuda Flight 152 (approaching)
• MEDAN is the Medan air traffic controller

Exchange between MEDAN and GIA 152 are in bold.

ATC tower communications

GIA 152: Medan Approach, Indonesia 152 passing 150. MEDAN: Indonesia 152 radar contact 43 miles. Descent to 3000ft for Runway 05, reduce speed to 220. GIA 152: Descend 3000 for Runway 05. Reduce speed to 220 kts., Indonesia 152. GIA 152: Approach, Indonesia 152, request reason to reduce speed above 10000 to 220kts. MEDAN: OK Sir, your traffic departure sir, now start engine, release traffic departure at or before 27. GIA 152: 152 like to maintain 210 kts... 250kts, and below 10000. MEDAN: OK, it's approved. MNA 241: Merpati 241 passing 10000. MEDAN: Merpati 241, your position now 11 miles on W-11. Contact 1212. Happy landing. MNA 241: Selamat siang. Terima kasih. (Good afternoon. Thank you) MEDAN: Any time. GIA 152: Indonesia 152; 3000 MEDAN: Indonesia 152, maintain 3000ft for a while. Maintain heading Medan VOR. Traffic now still taxi Runway 23. GIA 152: Maintain 3000. MEDAN: Merpati 152, turn left heading 240 vectors for intercept Runway 05 from right side. Traffic now rolling. (Note that the controller used the callsign of a flight earlier in the day. This call was meant for GIA 152) MEDAN: Indonesia 152 do you read? GIA 152: Indonesia 152, say again? MEDAN: Turn left heading a ...... 240, 235 Now for vectoring for intercept Runway 05. GIA 152: Roger, heading 235. Indonesia 152. GIA 152: Indonesia 152 heading 235. Confirm we cleared from a ..... mountainous area? MEDAN: Affirm sir! Continue turn left on heading 215. GIA 152: On heading 215, Indonesia. BOU 683: Good afternoon, approach. Bouraq 683 departed left turn MEDAN: Bouraq 683 continue turn left on heading 120 initial 2000ft. - One line missing in transcript - MEDAN: Indonesia 152 traffic now cleared descend to altitude 2,000ft GIA 152: Descending to 2,000ft Indonesia 152 MEDAN: Indonesia 152, turn right heading 046, report established on localizer. GIA 152: Turn right heading 046, Indonesia 152, check established. GIA 152: Indonesia 152 confirm turning Left or Right heading 046 MEDAN: Turning right sir. GIA 152: Roger, 152. MEDAN: 152, confirm you're making turning left now? GIA 152: We are turning right now. MEDAN: 152 OK, you continue turning left now. GIA 152: A ...... confirm turning left? We are starting turning right now. MEDAN: OK ...... OK. MEDAN: Indonesia 152 continue turn right heading 015. GIA152: Aaaaaah! Allahu Akbar! (God is great!)

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. 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.

The Indonesian authorities never released the results of their investigation of the crash, forcing the lawyers of the crash victims to file actions in the United Kingdom and France in order to obtain the flight record data from Flight 152's black boxes. The flight data recorder revealed that the warning from the GPWS had not sounded in the cockpit, due to the terrain the aircraft was flying. Since the pilots immediately pulled the jet into a climb once the mountain was visible and just barely clipped the treetops, 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.

In Coyle v. P.T. Garuda Indonesia, 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 737-800NG.

See also

• List of accidents and incidents involving commercial aircraft

External links

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