Garuda B738 at Makassar on Jun 2nd 2015, overran runway on landing

Last Update: January 4, 2017 / 16:13:57 GMT/Zulu time

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Photo of Garuda Indonesia PK-GFA, Boeing 737-800 — Garuda Indonesia PK-GFA, Boeing 737-800 (Photo credit: Aero Icarus / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Jun 2, 2015

Classification
Incident

Cause
Overran runway on landing

Airline
Garuda Indonesia

Flight number
GA-618

Departure
Jakarta, Indonesia

Destination
Makassar/Ujung Padang, Indonesia

Aircraft Registration
PK-GFA

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Garuda Boeing 737-800, registration PK-GFA performing flight GA-618 from Jakarta to Makassar/Ujung Padang (Indonesia) with 145 passengers and 8 crew, landed on Makassar's runway 13 at 14:34L (06:34Z) but overran the end of the runway and came to a stop with the right main gear on the paved surface of the runway end safety area and left and nose gear on soft ground. The passengers disembarked onto the runway end safety area and were taken to the terminal.

Runway 13/31 (length 2500 meters/8200 feet) was closed for about two hours until the aircraft could be moved off the runway.

On Jan 4th 2017 the NTSC released their final report concluding the probable causes of the serious incident were:

Unanticipated wind condition has made the pilot did not aware to the wind direction changes and resulted the aircraft floated for 13 seconds and touched down on the middle of the runway.

The captain (41, ATPL, 10,348 hours total, 3,906 hours on type) was pilot flying, the first officer (38, ATPL, 9,839 hours total, 1,894 hours on type) was pilot monitoring.

The aircraft was vectored for an ILS approach to Makassar's runway 13, the east of the airport was cloudy, the end of runway 13 was in rain with about one quarter of the runway at the end being wet.

Descending through 100 feet the Navigation Display showed the aircraft encountered 10 knots tailwind and 10 knots right crosswind.

Descending through 20 feet AGL the tail wind component however changed to a 6 knots headwind.

During the landing flare the thrust levers were pulled to idle, however, the aircraft floated and touched down only 1375 meters past the runway threshold about 13 seconds after crossing the runway threshold. After touchdown the aircraft encountered heavy rain.

The NTSC reported the crew did not consider a go-around or balked landing knowing, that there was mountaineous terrain ahead.

The aircraft came to a stop after a ground roll of 1095 meters. Seeing they were rapidly approaching the runway end the captain steered the aircraft slightly to the left, the aircraft came to a stop with the right main gear on the stopway and nose and left main gear stuck in mud.

The NTSC reported: "The ARFF (Airport Rescue and Fire Fighting) deployed to the location mentioned by the tower controller via taxiway WP (Whiskey Papa) and almost collided with the aircraft that was taxied on the taxiway. The visibility hampered the ARFF driver vision."

The passengers were subsequently deplaned via stairs.

The NTSC analysed:

The FDR recorded that after passing 20 ft AGL, the aircraft floated for approximately 13 seconds. During this period, the airspeed indicated 157 kts and decreased to 154 kts while touchdown. The ground speed was recorded 170 kts and decreased to 150 kts on touchdown. As of the ATIS before descend, informing that the runway in use was runway 03, wind condition 240°/7 kts (variable 200° - 290°), while the FDR recorded that 20ft the wind changed from tailwind 9kts to headwind 6kts.

This data showed that the ground speed has decreased 20 kts while the air speed decreased 3 kts. Slight decrement of air speed indicated that only slight change of air velocity movement on the wing surface. This condition resulted in minor changed on the lift produce by the wing. This means that the wing still produced sufficient lift to the aircraft and made the aircraft floated.

The significant differences between the reduction of the ground speed and airspeed was result of the change in wind condition, from tailwind to head wind. The change of wind direction might have not been anticipated by the pilot and ATC.

The black clouds and rain that visible by the pilot and ATC was indication that the cumulonimbus has reached the mature stage. During the mature stage, the downdraft will push down out of the thunderstorm, hit the ground and spread out.

This downward force created the headwind to the runway. The head wind from the downward force did not reach the final area and the final area was still affected by the local wind. This condition has made the aircraft has tailwind on final and changed to head wind while flew over the runway.

A steady approach on correct approach flight track the aircraft will touchdown at approximately 300 meters from the beginning of the runway. The calculation of the required runway length for the estimated aircraft landing weight with flaps 30 configurations was 2,100 meters, which means that the ground roll required was approximately 1,800 meters.

During the 13 seconds floated at ground speed of 170 kts to 150 kts, the aircraft has travelled for 1,075 meters over the runway. Based on this calculation, the aircraft might touchdown at approximately 1,375 meters from the beginning of the runway. The required runway for the aircraft to stop was approximately 3,175 meters while the runway length available was 2,500 meters. This calculation was relevant to the FDR data that the aircraft touch down at the middle of the runway approximately after passing the taxiway Charlie.

Metars:
WAAA 020900Z 08003KT 040V120 5000 TS FEW018CB SCT019 24/24 Q1010 RERA NOSIG
WAAA 020830Z 06004KT 4000 -TSRA FEW018CB SCT019 24/24 Q1010 TEMPO TL0900 07005KT 4000 -TSRA FEW017CB SCT019
WAAA 020800Z 10003KT 060V130 3000 -TSRA FEW018CB SCT019 24/24 Q1010 TEMPO TL0900 12005KT 3000 -TSRA FEW017CB SCT019
WAAA 020730Z VRB07KT 0800 +TSRA FEW017CB BKN018 25/25 Q1010 TEMPO TL0800 VRB08G20KT 800 TSRA FEW017CB BKN019
WAAA 020700Z 06010G20KT 350V110 0500 +TSRA FEW017CB BKN018 24/24 Q1009 TEMPO TL0800 10010G20KT 500 TSRA FEW017CB BKN019
WAAA 020630Z 22009KT 180V250 3000 TSRA FEW018CB SCT019 30/28 Q1009 TEMPO TL0800 24010G20KT 2000 TSRA FEW017CB BKN019
WAAA 020600Z 25010KT 200V280 9999 TS FEW018CB SCT019 32/26 Q1009 NOSIG
WAAA 020530Z 24007KT 200V290 9999 FEW019CB 33/26 Q1009 NOSIG
WAAA 020500Z 23005KT 170V290 9999 FEW019CB 32/26 Q1010 NOSIG
WAAA 020430Z 21005KT 150V260 9999 SCT020 32/26 Q1010 NOSIG
WAAA 020400Z 20006KT 9999 FEW020 31/26 Q1010 NOSIG