0:00

This is

0:02

a Rooster Teeth Production. September

0:08

26th, 1997. Garuda

0:10

Indonesia Flight 152, an Airbus A300 carrying 234 people,

0:15

is on approach to Polonia International Airport

0:17

in Medan, Indonesia after a flight

0:19

from Soekarno-Hatta International Airport

0:22

in Jakarta, Indonesia. Forest

0:24

fires in Riau, South Sumatra, and

0:26

Kalimantan have sent smoke covering the skies

0:29

across all of Southeast Asia, limiting

0:31

visibility to less than 500 meters. The

0:33

flight crew of Garuda Indonesia Flight 152 has

0:36

to rely on

0:37

air traffic control and their instruments to

0:39

guide them through their approach. With only one

0:41

runway and another aircraft departing, air

0:43

traffic control has to slow Flight 152 to

0:46

clear the way for their landing. Medan Approach

0:48

is attempting to guide Flight 152 by advising them based

0:51

on local radar vectoring guidance. While

0:53

being vectored in the smoke, the pilots realize with horror

0:56

they are flying straight into treetops on a mountain.

0:58

They attempt to add power and climb, but it is too late.

1:01

The plane slams into the mountainside and all 234

1:03

occupants lose their lives in

1:05

what would become the deadliest aviation

1:07

disaster in Indonesia's history

1:09

up to this point. Why did Garuda

1:11

Indonesia Flight 152 collide with

1:13

terrain while talking to air traffic control? Did

1:15

air traffic control make an error or did the pilots make

1:17

an error or was there some malfunction with the plane?

1:20

Find out on this episode of Black Boxed

1:22

Out.

1:25

Hello everyone, welcome to Black Boxed Out. It's Gus

1:27

and Chris. Hello, Chris. Hi. We're

1:29

here with another episode. You know, I realized something

1:31

the other day, Chris. I don't think we've

1:34

mentioned to our listeners that RTX is coming

1:36

up here in Austin. Oh, yeah.

1:38

It's

1:38

an event in Austin and

1:41

we'll be doing panel and, you know, meet and greets and whatnot

1:43

there. You should definitely check it out, rtxaustin.com.

1:47

Besides us, there's like a whole podcast festival track

1:49

there with a bunch of other podcasts. Some of the other podcasts

1:51

that we participate in and a bunch

1:53

of other Internet content stuff, comedy, video

1:56

games, you name it. Yeah, there's like live

1:58

comedy shows.

1:59

Also just a fun place to visit. Yeah.

2:02

If you've ever been to Austin and just want to check it out. July

2:05

7th to 9th this summer, just about two months

2:07

away at this point. Tickets are available. Again,

2:09

just head to rtxaustin.com,

2:12

get more information, pick up some tickets, come say hi. We're

2:14

doing a panel. I don't know what day the Black Box Down

2:16

panel is on, but we are doing one

2:18

and a little bit of spoiler, a little peek

2:20

behind the curtain here. I haven't told you this either, Chris.

2:23

Dennis is going to be on the panel with us. Our old writer, Dennis.

2:25

Dennis! As well

2:27

as Marcos, our current writer Black Box Down.

2:30

So if you've ever wanted to pick their brain as well about

2:32

the writing process for these episodes, they will also

2:34

be joining us on the panel.

2:37

That'd be great. Dennis did the craziest thing

2:39

as a tangent. Let's

2:41

save that for the panel at RTX. Okay, okay,

2:44

okay. Let's get to tell a story worth it.

2:46

Anyway. I think I know what you're going to say. And I

2:48

think

2:49

it's a good thing to bring up at the panel at RTX

2:52

here in about two months. Again, rtxaustin.com.

2:55

Anyway, that's later. This is now. We're

2:57

talking about Garuda Indonesia flight 152.

3:00

I don't know if we've talked about a Garuda

3:02

incident in the past. I think we have, but

3:05

just as a recap, Garuda Indonesia

3:07

is the flag carrier for Indonesia. It's the country's

3:09

second largest airline after Lion Air.

3:12

And it's headquartered at Sohara Nohada International

3:14

Airport in Jakarta. Man, is

3:16

this bad? All I think about is

3:19

it's not Garuda Valley in Zelda,

3:21

is it? Garudo Valley.

3:24

Oh, Garudo. Yeah, yeah, yeah.

3:26

The rock eating guys, right? No, no. It's

3:29

like the Garudo

3:30

Valley is like the kind

3:32

of like desert-y region

3:35

where they have like, it has the music.

3:37

They just da da da da da da da. Oh

3:40

yeah, yeah, yeah, Garudo. Yeah, yeah,

3:42

yeah. I got you. I'm thinking of something

3:44

else. Yeah, no, no. It's similar, but not quite.

3:47

That's G-E-R-U-D-O.

3:49

Garuda is G-A-R-U-D-A. Yeah,

3:53

yeah.

3:54

And there's some listeners right now who

3:56

are like, what? It's a video game thing. Sorry.

4:00

No, no, it's it's good to to because

4:03

spell it out right guy try to get it to make

4:05

sure they don't they're thinking about The

4:07

the area in Zelda Ocarina of

4:09

time. Yeah Zelda as far as I know only

4:12

has gliders And yes, there is

4:14

no powered flight as far as I remember.

4:16

It's been a little while anyway

4:18

Garuda Indonesia flight 152

4:20

was captained by Hans Rachmo We

4:23

go who

4:23

is a 41 year old pilot with 19 years of

4:25

flying experience at Garuda and had

4:28

nearly 12,000 flying hours and

4:30

the first officer was Tata Zewaldi who

4:32

was also 41 and

4:34

He was a former flight engineer who

4:36

had recently transitioned to becoming a

4:38

pilot. Remember this is 1997 Oh,

4:41

yeah, he was like I'm out of a job Right.

4:43

He's like, oh if I want to stay in the cockpit

4:45

of a plane I need to move from that chair

4:47

which no longer exists to that chair over there

4:49

which is going to continue to It's actually interesting. I don't know

4:51

if we talked about that. But like yeah, I guess that was a very

4:54

I

4:54

bet a lot of engineers did that

4:57

Probably. Yeah, I don't I don't have any figures

4:59

or numbers on that But they would already be fairly

5:01

familiar with this. I mean pretty familiar with the systems.

5:04

They probably

5:05

Needed training on how to actually

5:07

do the flying aspect But as far as the systems

5:09

and everything they would probably know all of that Yeah Because

5:12

we've talked about before like to handle radio calls Whenever

5:15

there was an engineer if something was going wrong

5:17

they would manage a checklist and run over

5:19

the different things and look at it all and they know

5:21

like the

5:22

Theoretically how to fly the plane probably right

5:25

this probably just like the actual

5:27

physical act of doing it

5:29

anyway The captain captain we go was familiar

5:31

with Polonia International Airport He made

5:34

little flight numerous times

5:35

and this plane that they were flying

5:38

an Airbus a 300

5:39

It was referred to or this Pacific airplane was

5:41

all was what they called a FF CC

5:44

It stood for forward-facing crew

5:47

concept.

5:48

It's a modified version of an

5:50

Airbus a 300 in which the flight

5:52

engineer station is eliminated And

5:54

the relevant controls are simplified and relocated

5:56

to be positioned

5:57

on the overhead panel between the two pilots

5:59

Presumably this was a plane that originally

6:02

had a flight engineer seat,

6:04

then they modified it to get rid of that and

6:06

repositioned all of the controls

6:09

so that two pilots could operate everything.

6:12

Okay, yes, makes sense. The aircraft

6:14

was powered by two Pratt & Whitney turbofan

6:16

engines and had about just under 27,000 hours,

6:18

it was 26,950 hours and 16,500 takeoff and landing cycles at the time of the

6:25

accident. This flight departed from

6:27

Jakarta at 441 universal

6:30

time and it was regular scheduled

6:32

passenger flight to Polonia International

6:34

Airport in Medan

6:36

with an estimated arrival time of 641 universal

6:39

time, so about a two hour flight.

6:41

At 1.13 pm

6:43

local time, air traffic controllers

6:46

in Medan cleared flight 152 for an ILS approach to

6:49

runway 5 from its heading

6:51

of 316 degrees. So

6:54

ILS approach means they're going to do an instrument approach,

6:56

remember there's heavy smoke there's wildfires in the

6:58

area or forest fires in the area that are obscuring

7:01

visibility so they can't see very far, so

7:03

they're going to do this instrument approach. That's

7:06

like a crazy anomaly, I don't think we've

7:08

talked about before,

7:10

wildfire smoke? We've talked about

7:12

volcano smoke before, but

7:16

yeah, I mean it happens, you know,

7:18

it's just

7:19

another phenomenon you have to deal with. I mean, if

7:21

you think about it, it's like clouds also

7:23

obscure visibility quite a bit, you know, so

7:26

it's not

7:26

necessarily any more dangerous per se, maybe

7:29

it

7:30

might smell a little bad but you know,

7:32

you should be able to deal with this. And then also to

7:34

clarify some of the things I was saying, they're on a 316 degree heading, so

7:37

they're flying

7:38

northwest and if they're cleared

7:40

for runway 5,

7:41

runway 5 would be kind of in

7:43

the direction of northeast.

7:45

So you know, they're flying towards northwest and they're going

7:47

to have to kind of turn to the northeast to get

7:49

to that heading because runway 5

7:52

indicates that it would be at a 0-5-0

7:54

heading if you're

7:56

thinking about a compass, north is 0, south

7:58

is 180, east is 30.

7:59

West is 270. There's

8:01

only one runway at

8:03

this airport and there was another flight departing

8:06

at that time.

8:07

And they were departing on runway 23. So

8:09

it's the same runway, but they're departing to

8:11

the southwest. This incoming

8:13

plane is going to be landing on that same runway to

8:15

the northeast. So they don't, you

8:17

know, they're trying to space them apart. So air traffic

8:20

control tells flight 152 to slow

8:22

down a little bit, give this other plane space

8:24

to take off, and then they're gonna vector them in

8:26

to come in to land. And that's all pretty

8:29

normal stuff.

8:30

Yeah, the only potential wrinkle,

8:32

the only like slightly weird thing here is

8:34

that a plane's taken off in one direction,

8:37

and then this plane's coming in to land in the opposite direction.

8:40

Normally, you know, you use the runway in

8:42

one direction. Everyone's taking off and landing,

8:45

you know, in one direction. Okay.

8:47

So that's a little strange. But

8:50

at this airport, it happened. I did look

8:52

into it a little bit and it wasn't uncommon

8:54

at this airport. It is a

8:56

little strange though. So less than 15

8:58

minutes from landing, flight 152 descends

9:00

through 10,000 feet, and they hit that really

9:02

thick smoke, which limits their visuals

9:04

and forces them to depend on their instruments

9:07

and air traffic control instructions.

9:09

And the pilots were instructed to turn left

9:12

to a heading of 240 degrees to

9:14

intercept the ILS localizer. That's the

9:16

so their instruments come alive and work and can guide

9:19

them down to the runway.

9:20

If they're heading 240,

9:22

they're pretty much heading

9:23

exact opposite of the runway. Because remember, the runway

9:25

is 050. So 190 degrees difference

9:28

or 170 degrees, depending on how you

9:29

look at it. They're

9:32

pretty much flying in the opposite direction, presumably

9:35

to turn around, you

9:36

know, do a 180 degree turn and come back and land

9:38

on the runway. A little bit of math,

9:40

a little bit of a... So

9:43

remember, they're flying on this 240 heading, and

9:46

then two minutes prior to the impact, the crew

9:48

was asked to turn a little further left to 215 degrees,

9:51

presumably to space them out a little more.

9:54

At 1 30 p.m., Madan instructed the crew

9:56

to descend to 2000 feet and to turn

9:58

right, heading 046 degrees.

9:59

degrees to line up for arrival onto runway

10:02

five. Remember this is what I said.

10:04

They were flying kind of opposite the runway and

10:06

now they're being asked to make that right turn to

10:09

line up and come in to land. The crew

10:11

was asked to report the direction in which the plane was traveling.

10:13

At this point this is when the confusion starts

10:16

because air traffic control

10:18

became confused about what plane they were talking

10:20

to because

10:21

a little earlier there had been another flight

10:24

with the same number. Remember

10:25

this we're talking about Garuda Indonesia

10:27

flight 152. A little

10:29

earlier air traffic control had been talking

10:31

to Murtadi Nusantara Airlines

10:33

flight 152. So the air

10:35

traffic controller by mistake

10:37

instead of saying Garuda 152 he said Murtadi 152

10:40

turned left heading 240 to

10:43

intercept runway 05 from the right side.

10:46

So you see he said the wrong thing so since he didn't say

10:48

Garuda the pilots

10:50

didn't listen they assume you know he says he's talking to

10:52

someone else so you know the pilots

10:54

are still going through their stuff. Even though it

10:56

was

10:56

otherwise the same. Right because

10:59

totally different call sign

11:01

just happens to have the same flight number.

11:03

So of course the Garuda pilots don't

11:05

listen to this they assume someone else is you know they're

11:07

talking to someone else and the controller doesn't get a reply

11:10

so again he asks to get their attention he says

11:13

Indonesia 152 how do you copy

11:15

or how do you hear

11:16

and they're like oh

11:17

he's talking to us. You know the pilots are like oh he's talking

11:19

to us so they're like Garuda 152 we hear you. So

11:22

then the controller has to repeat his instructions.

11:25

Remember what he said earlier was Murtadi 152

11:28

turned left heading 240 to intercept runway 05

11:32

from the right side. So he repeated those

11:34

instructions except he omitted one

11:36

specific part. You know when he repeated it he

11:38

told he said Garuda 152 turned

11:40

left heading 240 to intercept runway 05.

11:43

He didn't specifically say from the right side.

11:46

Oh

11:46

wait from the right side of the runway.

11:49

The runway. This is maybe something

11:51

that you might not think about or most passengers

11:54

might not think about but if you imagine a runway

11:56

right imagine you're a plane coming to land

11:58

on the runway and most

11:59

planes. We've talked about this before about traffic

12:01

patterns and this specific plane

12:04

was flying the opposite direction of

12:06

what they were gonna land. So they're flying essentially

12:08

parallel to the runway in the wrong direction.

12:10

Planes can either be on the left

12:13

side of the runway or the right side of the runway. These

12:15

are called either like left traffic patterns or right traffic

12:18

patterns, if you're talking about. Like a

12:20

car has the left and right lane?

12:22

It's like an invisible lane up in

12:25

the sky. It's like when you're flying parallel

12:27

to the runway on what they call the downwind.

12:30

When you make your turn to actually

12:32

get on final and line up with the runway, you

12:34

could either turn right or turn left depending

12:36

on what side of the runway you're on.

12:38

Sometimes some

12:40

airports and some runways specify

12:43

you have to be on this side or you have to be on that side. But

12:45

then sometimes air traffic control will just

12:47

vector you around whatever makes the most sense with other traffic

12:49

in the area.

12:51

And remember, since visibility was poor,

12:54

the pilots can't see the airport, they can't see the

12:56

runway. And this is also in 1997,

12:58

GPS isn't as prevalent. They don't know

13:01

exactly where they are. So they're kind of

13:03

relying on air traffic control to tell them where they are

13:05

and give them their instruction. So the normal

13:07

approach into this airport

13:10

would have had the pilots coming

13:12

in on the north side of the runway, which

13:14

meant they would have turned left to get lined up

13:16

and land on the runway. But in reality,

13:18

they were on the south side of the runway, so

13:21

they would have to turn right to line up.

13:23

So it's just like this weird little thing. Which

13:26

direction you circle around? Yeah,

13:29

exactly. Sorry, yeah, I misunderstood that. I

13:31

thought you meant like there were

13:33

like two lanes, but you're just

13:35

saying which direction they turned to circle.

13:38

Correct, or not to circle necessarily,

13:40

but to like, it is a circle, but it's

13:42

to come in to line up and land, line up with

13:44

the runway and land. Do a 360 to?

13:47

A 180. Yes,

13:50

a 180 to line up to land. Yes,

13:53

exactly. So it can be a little

13:55

confusing. After a while,

13:57

it kind of becomes second nature.

13:59

Again, this is 1997, there's no

14:02

GPS,

14:03

and so they're kind of relying on

14:05

air traffic control to tell him here. And when air traffic control repeats

14:07

himself, he doesn't clarify that

14:10

they're going to be on the south side of the field. So

14:12

it's just like this one little bit of information that gets omitted.

14:15

So the pilots assume they're approaching

14:17

from the north side of the airport, which is the

14:20

standard way. It's on the charts, it's

14:22

what normally you would do.

14:24

But again, like I said, sometimes air traffic control can

14:27

amend that if there's

14:28

other traffic. And in this case, there was a plane

14:30

departing,

14:32

which I mentioned earlier, and it was departing

14:34

out to the north. So air traffic control was keeping this

14:36

plane incoming to the south to keep

14:38

them spaced apart.

14:40

So all of that, sorry, I know that's like a mouthful, it's

14:42

a ton to get through.

14:43

All that is to establish that when the pilots

14:45

were ultimately instructed to turn right to

14:47

a heading of 046 and maintain 2,000 feet

14:50

to get the localizer

14:53

for the ILS on runway five, out

14:55

of a force of habit, the captain, instead

14:57

of turning right as he was instructed, turned

14:59

left. Because

15:02

normally, again, normally you're supposed

15:04

to turn left. The chart says turn left,

15:06

but he was told to turn right. And

15:09

then maybe because, like I said, he'd been here many

15:11

times, it's just like a force of habit. He turned

15:13

left instead of turning instead of turning right.

15:15

And air traffic control omitted

15:18

that the second time.

15:19

They did not omit it the second time. They

15:22

omitted it when they first told the pilots

15:24

what they were going to be doing. You

15:25

know, when the air traffic control finally does

15:27

tell him

15:28

to turn to 046, he does say turn

15:30

right to 046. But the

15:33

captain, just out of force of habit, turns left. The

15:36

next question someone might ask is, well, why

15:38

did the first officer not notice that the captain

15:40

turned the wrong direction?

15:43

Well, due

15:45

to, I guess, what you could call bad luck,

15:48

right at that moment, the captain

15:50

was complaining that the cabin was

15:52

hot. And he asked the first officer to look

15:54

and check and make sure the air conditioner was on and working.

15:57

So the first officer looks up to

15:59

check the air conditioner. the captain begins

16:01

this left turn.

16:02

And the first officer is fiddling with the air conditioner and

16:06

says, no, the air conditioner is working. And when

16:08

he finally looks down again at the instruments,

16:11

he does tell the captain, hey, we're turning the wrong

16:13

way. Oh, he does. Yeah. And

16:15

the captain

16:17

at this point

16:18

radios back to the controller and asks the controller, hey,

16:20

which way do we need to turn? And the controller

16:22

confirms, right turn 046.

16:25

So then now things become even more

16:27

confusing. So the plane is turning

16:30

to the left. They were supposed to turn to the right. They asked the

16:32

air traffic controller, hey, which way we're supposed to

16:34

turn? Air traffic controller says to the right.

16:36

So the pilot says, OK, we'll

16:38

turn right. And the air traffic controller says, continue

16:41

left turn.

16:42

And the captain says, but we're turning right

16:44

now.

16:45

What do you mean continue left turn? And the

16:47

air traffic controller at this point doesn't really

16:49

have an entirely clear picture of what's happening. It's

16:51

like a who's on first situation. Yeah.

16:54

He's like, but you said turn right. Was he saying,

16:56

no, go ahead and continue your left turn?

16:58

Is that what he was saying? Exactly. That's what

17:01

he meant to say. It's like, OK, well, you already turned left. Continue

17:03

that left turn. That's how I interpreted

17:05

that. Right. But the captain

17:07

thinks,

17:08

oh, he thinks we're still turning the wrong

17:10

direction. I need to correct him. We're actually turning

17:12

right now. So he turned, started turning

17:14

left, and then did, so he was kind of doing like an

17:16

S shape. Exactly. Yeah, it's exactly

17:19

a big S shape in the sky that he's doing.

17:21

And the air traffic controller doesn't have

17:23

a very

17:24

quickly updated picture of what's going on. Because

17:27

his radar screen

17:28

is only refreshing every 12 seconds.

17:31

Seems slow. That's really slow.

17:33

Most modern radar should refresh about every five

17:36

seconds. They had an older system here. Yeah,

17:38

I'm thinking about like movies. They go bloop,

17:41

bloop. Yeah. Right?

17:44

Which is about four or five seconds, right? Yeah, the

17:46

five seconds is, it should be pretty standard.

17:49

12 seconds is long. Wait, it's really like

17:51

bloop.

17:56

That is that. That's a lot. It's

18:00

a long pause. And if you think about how fast a plane is going,

18:02

they can cover a lot of ground in that amount

18:05

of time. Because the radar was slow

18:09

and not getting this constant up-to-date view of

18:11

what's going on, the controller thought the

18:13

plane was continuing left when in reality,

18:15

like you said, it's making this S turn kind of

18:17

deal and it's turning right. And it's

18:20

at this point, since they

18:21

initiated that turn to the left, they're getting close

18:23

to mountains and high terrain.

18:25

Oh no. And while all this

18:27

is going on, the flight descended below

18:30

their clearance of 2000 feet.

18:32

Remember they were told, maintain 2000 feet

18:34

and make this right turn. Well, instead they turned

18:36

left and dipped below 2000 feet. Why'd

18:38

they do that? This is one of the

18:41

parts of the report that's

18:43

unclear.

18:44

After the crash, the systems where

18:46

they could go through and figure this out were a

18:48

little too damaged for them to figure it out. The speculation

18:51

is that when the 2000 foot limit

18:54

was entered into autopilot, the captain may

18:56

have mistakenly put 200 feet instead

18:59

of 2000. Oh no. So the pilots didn't

19:01

notice because they were focused

19:03

on turning to the correct heading. They're

19:05

looking around, focused on this other problem and

19:08

they don't notice that

19:09

the plane is dipping below 2000 feet.

19:11

That's such a big difference though. 200 to 2000,

19:16

I mean. Well,

19:19

who knows, stuff's going on. The

19:21

captain's uncomfortable with the heat. Remember he'd

19:23

complained that it was a little hot up there. The

19:25

first officer wasn't double checking everything.

19:27

And we're actually gonna talk about this, about why this

19:29

wasn't caught a little more, a little more further

19:32

in this episode. But

19:34

five seconds before the impact with the treetops,

19:37

the first officer made a comment about the airplane's altitude.

19:39

First officer at least is noticing stuff. Right,

19:43

maybe a little too late though. Yeah.

19:45

And the flight data recorder

19:46

at this point records an increase in pitch and

19:49

engine power.

19:50

Most likely, you know, the crew

19:51

gives it more power and tries to climb

19:54

realizing that they're too low in order to correct

19:56

their altitude. Mm-hmm. And

19:58

shortly before the recording ended, cockpit voice recorder

20:00

registered the sound of the plane striking

20:03

trees followed by some shouts. And

20:05

in spite of the immediate corrective action taken by

20:07

the crew, the aircraft struck a tree top on a

20:09

ridge about 1,550 feet above sea level.

20:13

So remember, at this point then they were about 500 feet lower

20:15

than they should have been. Instead of being at 2,000, they were at 1,550.

20:19

Which is a lot. That's a lot lower.

20:22

That's significant, yeah. This tree

20:24

impact separated about nine feet of

20:26

the right-hand wingtip,

20:28

which made the aircraft uncontrollable,

20:30

spilled fuel till it hit the ground in

20:32

an abandoned rice field at the bottom of

20:34

a ravine about 600 meters from

20:36

the first tree impact.

20:38

The aircraft hit the ground at about 1.32 p.m. local time

20:41

and the wreckage was found about 17 miles

20:43

southwest from the airport

20:45

near the village of Oana Bar,

20:47

Subonlungit. When the investigators found

20:49

the crash site,

20:50

locals had already begun carrying away parts from

20:52

the wreckage compromising the investigation.

20:54

And

20:55

we've talked, this happens sometimes. It's

20:58

like a lot. Yeah,

21:00

and they were actually really worried

21:02

for a while because it

21:04

took them a while to find the black boxes.

21:06

I think it took them almost four weeks. It took them like 26 days

21:09

and they were worried, oh man, did someone carry it off

21:11

before

21:12

we could get there and secure the site?

21:14

But they eventually found it. It

21:17

was still there. It just had gotten a little buried in the mud.

21:19

So normally, like you commented,

21:21

like we both commented, they were pretty low

21:24

here. They were at 1,550 feet when

21:26

they should have been about 2,000 feet.

21:28

And normally, there's

21:29

around an airport, there's what's called like

21:31

a minimum safe altitude where within a certain

21:34

distance of the airport, there's like an altitude you

21:36

should not get below because if

21:38

you go any lower, there's potential terrain.

21:40

And presumably, they dipped below

21:43

that minimum safe altitude here when

21:45

they got below 2,000 feet. And

21:47

obviously, we're in the wrong direction. They were out over the mountains

21:49

instead of by the airport. If they

21:52

had turned the right direction and

21:54

done the same S, would

21:57

they have been okay? Yeah. If

22:00

they turn to the right, yeah, because

22:03

the airport is kind of situated a

22:05

relatively safe distance from the mountain. So by

22:07

turning the incorrect way,

22:09

they close that distance and, you know, and their radar

22:12

is updating so slowly, their traffic control doesn't see

22:14

it until they're right on top of the mountain.

22:16

So due to the lack of access to the site by

22:18

wheeled or tracked vehicles and the very boggy terrain,

22:20

there's only a limited number of wreckage items that were

22:22

recovered from the accident site.

22:24

Things like instruments, avionics boxes,

22:27

some pieces of the right-hand wing and the frame-mounted

22:29

cradles. Into which the black boxes

22:31

were mounted.

22:32

The digital flight data recorder and the cockpit

22:34

voice recorder were recovered together on

22:37

October 21st, 1997.

22:39

Untangled in the roots of a tree about 50 centimeters

22:41

apart

22:42

and 20 meters from the rear fuselage located

22:45

in a soft and moist soil at

22:47

a depth of about half a meter under the ground

22:49

surface.

22:50

So October 21st, yeah, almost almost a month,

22:53

like 26 days or so.

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So now that's. That's everything that

26:00

happened. Now we're gonna talk about the investigation.

26:02

I gotta figure out why did this happen? Although

26:06

it seems pretty clear already what's

26:08

going on. I guess like how

26:10

to prevent it. Right, yeah. What

26:12

lessons can you learn from this? Or

26:15

maybe like who's exactly at fault. Right.

26:18

And how can you train to

26:20

prevent this kind of thing from happening again? So

26:23

before the flight even started, the flight crew reported

26:25

to Garuda Indonesia Flight Operations Office to

26:27

receive flight briefings, NOTAMs, which

26:29

are Notice to Air missions.

26:31

Back then they were called Notice to Airmen. Weather conditions

26:34

and forecast and route at destination,

26:36

alternate airports and flight plans. So everything

26:38

you think you would need as a pilot for your

26:40

flight.

26:41

And the NOTAMs, I think we've talked about NOTAMs

26:43

before. They're just like alerts, things that

26:46

are out of service, things that you

26:48

might need to be aware of that might affect your flight.

26:50

And the NOTAMs stated that the

26:52

MDN VOR was overdue for maintenance

26:55

and advised to use the facility with caution.

26:57

And VORs are navigation aids. Before

27:00

GPS, these are like the navigation aids that

27:03

planes would use to get around and navigate.

27:05

They're still in use. They're

27:06

starting to be phased out because GPS

27:08

is

27:09

so much more ubiquitous at this point. Anyway,

27:12

the NOTAMs just said that this VOR was

27:14

due for maintenance and to use it

27:16

with caution.

27:18

And although the MDN VOR had been

27:20

calibrated with both ground and flight calibration

27:22

on June 14th, 1997, and it was valid

27:25

until December 14th, 1997,

27:27

use of it was classified as restricted

27:29

due to radial course alignment at 270 degrees

27:32

radial.

27:33

The way VOR works is

27:35

you tune your navigation

27:38

instruments to it. Like it has a frequency it transmits

27:41

on.

27:41

And based on using the instruments,

27:44

you can tell what radial off of

27:46

the VOR you are, which kind of gives you an idea.

27:48

And if you have distance measuring equipment, it'll tell you how far

27:51

away you are. So you can tune it and be like, oh,

27:53

we're on the 180 radial off

27:55

of the MDN VOR, which means you're

27:57

directly south of it.

27:59

Or you're like.

27:59

And it just uses all the degrees

28:02

and you can picture in your head where you are

28:04

based on this fixed point. So you know where

28:06

you are. So that's why they say it's restricted

28:09

due to radial course alignment on the 270 degree radial. That's

28:12

telling you there may be some alignment issues with

28:15

using it if you're at the 270 degrees, if

28:17

you're west of it.

28:18

At the time of flight planning, the visibility from the Medan

28:21

area was about a thousand meters

28:23

in smoke.

28:24

The dispatcher stated he had received information

28:27

through company channel that the actual visibility at Medan

28:29

was 400 meters in smoke,

28:31

which was below the minimum required visibility

28:34

for the runway five ILS of 800 meters. So

28:37

when they were planning before they took off, the visibility

28:40

was being reported as 1000 meters because

28:42

of the smoke. But

28:44

in reality, when they got there, it was at about 400 meters

28:47

and the minimum visibility required was 800 meters. So

28:50

there was even less visibility than was required

28:52

to do this

28:54

instrument landing. So it was bad.

28:56

So that means no plane should

28:58

have been landing on that runway, is that? Correct,

29:01

they're below minimums. They should not be landing.

29:03

They should have shut down the airport. Yes,

29:05

or unless they have other landing

29:08

systems that would allow them to land with less visibility,

29:11

which I don't know, I don't think they did, but correct.

29:14

They should not be authorizing people to

29:16

do the runway five ILS with

29:18

this visibility because it's below the minimums required.

29:21

ILS is instrument landing, right?

29:24

Yes, but you still need to have a certain degree of visibility.

29:27

So

29:28

what you say, unless they had more equipment,

29:31

like what more could they have?

29:33

So there's different degrees of

29:36

ILS approaches. Yeah, the most,

29:39

as far as I know, the most precise

29:41

one is what they would call a category three ILS approach.

29:43

And that's essentially auto landing.

29:46

That's essentially the planes coming down to the runway. I think

29:48

at that point,

29:50

you need to be able to see the runway once you're like 20 feet

29:52

above it or something. It's like ridiculously

29:54

short. And the visibility is near

29:57

nothing. I don't know what the visibility requirement

29:59

ILS is but it's super

30:02

small. I didn't know there were degrees of it.

30:04

Yeah, there's there's there's varying degrees of ILS

30:08

so the standard ILS like they were doing here like we mentioned

30:10

the you know their minimum required visibility for it was 800

30:12

meters You

30:14

know in the US we would say it's about half a mile

30:16

and that's for this category one ILS

30:18

if you're dealing with like a category three ILS

30:21

approach the visual range needed

30:23

is about

30:24

700 feet or 200 meters So

30:27

even at 400 meters a category three

30:29

still has double what it needs to be able to

30:31

land with cat 3 ILS a big difference.

30:34

Yeah big difference

30:35

in my head. It was just one It's either you

30:37

got it or you don't is it and

30:40

even nowadays There's also other

30:42

kinds of approaches now that we have GPS

30:44

is GPS based approaches They call them are nav approaches

30:47

that have a whole other set of requirements and

30:49

visibility requirements as well

30:51

But

30:51

yeah, so to answer your question. Yes,

30:53

they should not be landing like this

30:55

at 6 12 and 51 seconds

30:57

universal time Gerudo 152 requested

31:00

a descent clearance to a Medan control

31:02

Medan control cleared the flight to the center flight level 150

31:05

which is 15,000 feet and on passing

31:07

flight level 150 Gerudo 152 was

31:09

informed that the aircraft was in radar contact

31:12

at a distance of 43 nautical miles from

31:14

the Medan VOR The crew was then instructed

31:17

to send to 3,000 feet for a landing on runway 05

31:19

and to reduce the speed to 220 knots to

31:22

allow BOROC flight 683

31:24

to take off from one way to three at 620 and 47

31:28

seconds Gerudo 152 requested a

31:30

speed of 250 knots below 10,000 feet

31:32

which was approved side note I

31:34

don't know if you know this and that's the speed

31:36

limit. I don't know if you know planes

31:38

have speed limits Oh below 10,000 feet.

31:41

You can't go faster than 250 knots. Not like So

31:44

I just imagine like

31:46

plane speeding and then like

31:49

getting pulled over by a police You

31:52

know how fast you're going back You

31:55

know what the speed limit here is? Yes, sir 250 knots.

31:58

It's just because below 10,000

32:01

you're more likely to encounter smaller

32:03

planes that don't go as fast. So,

32:05

you know, want to make sure that

32:06

it's a safe speed and that people aren't just

32:09

going like five or 600 knots, you know, at

32:12

that low of an altitude where you might run into

32:14

a Cessna that's doing 80 or 90 knots. It's

32:16

just

32:17

a safety thing.

32:18

At 627 and 12 seconds,

32:20

Medan approach instructed Gerudo 152 to

32:22

maintain altitude on heading to the Medan

32:24

VOR, and

32:25

Gerudo 152 confirmed this nine

32:28

seconds later.

32:29

A little after that, about 30 seconds later, Medan approach

32:31

transmitted an instruction saying,

32:33

Merpati 152, you

32:36

turned left heading 240, vectoring

32:39

intercept ILS runway 05 from the

32:41

right side, traffic now

32:43

rolling. And there was no response because,

32:46

like we said,

32:47

Merpati 152 was earlier, Gerudo 152

32:49

doesn't think this instruction's for them. Yeah. A

32:52

little later, about 16 seconds later, Medan approach

32:54

radios again saying,

32:55

Indonesia 152, do you read?

32:58

And Gerudo 152 asks air traffic control to repeat.

33:01

Then Medan approach instructed Gerudo 152, turn left 240,

33:03

235 now, vectoring for intercept ILS runway 05.

33:10

And

33:10

the instructor was acknowledged by Gerudo 152.

33:12

Do

33:12

they ever call out that they had the wrong plane name? No,

33:15

I think the air traffic control realizes he said the wrong

33:17

thing and then just never clarifies.

33:20

Then at 628 and 52 seconds,

33:23

the captain asked Medan approach whether the aircraft

33:25

was clear from the mountainous area northwest from Medan. And

33:27

this was confirmed by Medan approach and Gerudo 152

33:30

was instructed to continue turning left on

33:32

heading 215.

33:34

This is a potential

33:36

to have caught this issue. The

33:39

pilot's asking if he's clear from the mountains northwest

33:41

of Medan because he thinks he's north of the

33:43

airport. The controller should have, at

33:45

this point, clarified,

33:47

besides just saying, yes, you're clear from those mountains, should

33:49

have said, yes, you're clear. You're on the south side

33:51

of the airport.

33:53

Right? Like this is just one of those weird things. They think their

33:55

traffic controller should have been like, yeah, of course he is. Why

33:57

is he asking that? And then clarified, you know, just.

33:59

is like dig into it a little more.

34:01

At 629 and 41 seconds, Gerudo 152 was instructed to

34:05

descend to 2,000 feet. The crew acknowledged it. The

34:08

flight data recorder indicated the

34:10

aircraft was wings level, heading 225, passing

34:13

through 3,000 feet on descent.

34:14

Then at 630 and four seconds, they

34:16

were instructed to turn right, heading 046 degrees,

34:19

and to report when established on the localizer. And

34:21

this is where the

34:22

mix-up happens.

34:23

This was acknowledged by Gerudo 152, but

34:26

misread the heading.

34:27

Turn right, heading 040, Indonesia 152,

34:31

check established.

34:32

And then the captain literally says, turn

34:35

right. He acknowledges it's supposed to be a right turn. He

34:37

says, turn right. And then

34:39

he turns the airplane to the left, and then pass

34:41

through, at this point, passing through 2,600 feet on the descent. At 630

34:45

and 33 seconds, so 29

34:49

seconds after the instruction, they're turning

34:51

left. The first officer reminded the captain,

34:53

turn right. Two seconds later, the

34:55

captain radioed Medan approach,

34:58

whether the turn is to the left or to the right,

35:00

onto heading 046 degrees. And

35:03

then at 630 and 39 seconds, or six

35:05

seconds after that, Medan approach replied, turning

35:07

right, sir, which was acknowledged by Gerudo 152.

35:11

And now the flight data recorder shows the aircraft

35:13

begins to roll to wings level.

35:15

At 630 and 51 seconds, Medan

35:17

approach asked whether Gerudo 152 was making a left

35:19

turn or a right turn. And the flight data

35:21

recorder information indicates the aircraft was wings

35:23

level, and beginning to roll to the right.

35:26

Their heading was about 135 degrees and increasing.

35:28

At 2,035 feet of altitude, on descent,

35:31

Gerudo

35:33

response, we're turning right now.

35:36

At 631 and five seconds, Medan approach instructed

35:38

Gerudo 152 to continue turning

35:40

left. Remember this is where I say, they

35:42

enter that who's on first conversation. And

35:45

the flight data recorder shows the

35:47

aircraft has passed below 2,000 feet altitude, is

35:49

still descending, and Gerudo 152 replies, confirming

35:53

turning left, we're starting to turn right now.

35:55

They would have been totally fine if they'd stayed above 2,000, right? That's

35:58

like-

35:59

They would have probably been- Okay. They just hit the tree

36:01

tops. If they had said it 2000, they would have

36:03

been okay. If they'd continue turning left, they would have been okay.

36:06

There's just

36:07

so many little miscommunications.

36:09

Right. Even the delay, you know, in, in doing

36:12

this, you know, we're now at six 31 and five

36:14

seconds. The initial instructions

36:16

happened at six 29 and 41. So

36:19

a minute and a half has passed at this point

36:21

and they're still, you know, going in the wrong direction

36:24

and kind of just messing things up.

36:25

And during the interview, the controller

36:28

said it was around this time. He recognized

36:30

that the aircraft went below the required altitude.

36:32

It was at 1800 feet and descending and

36:34

the flight data recorder indicates the aircraft reduced

36:37

its right role from about 24 degrees to 10 degrees and

36:39

then rolled right again, approximately 25

36:42

degrees

36:43

while the heading was increasing indicating

36:45

a right term was being maintained and the aircraft continued

36:47

descending. So they're still turning right and descending

36:50

at six 31 and 32 seconds. The sound

36:52

of tree impact is recorded. The elevation

36:54

of the initial impact for trees was at about 1,550 feet.

36:58

The final impact

36:59

on the bottom of a ravine, we set that 600 meters

37:02

from the first tree impact. So I

37:04

think at this point, the other question people might

37:06

have is why did

37:09

ground proximity warning system not go off? Oh

37:11

yeah. We know we've talked about, there's a system where, you

37:13

know,

37:14

normally when you get close to the ground, there's

37:16

that

37:16

kind of robotic voice that says like terrain, terrain,

37:19

pull up, pull up. And the aircraft

37:21

was equipped with a ground proximity warning system

37:23

and the flight data recorder

37:25

shows that the system was triggered

37:28

five times. What? But

37:30

even though it was triggered five times, it never actually

37:33

gave any alerts. It never gave an

37:35

audible alert. It never alerted

37:37

the pilots

37:38

the way it's supposed to. It went off five

37:41

times and never once told the pilots anything.

37:43

Why though? Like how, how that,

37:46

didn't that defeat the purpose of, it

37:48

really does defeat the purpose of it, doesn't it? Yeah.

37:51

Well, it turns out that there

37:53

was a flaw in ground proximity warning

37:55

systems that prevented the warning from

37:57

sounding

37:58

when it was descending over.

37:59

certain mountainous terrain. But

38:02

that's when you'd want it. Right. And

38:04

there was just a flaw in the system.

38:06

So it didn't give, it didn't sound any

38:08

alarms.

38:09

How does that work though? Didn't like,

38:12

how does that just, well, we have a bug to work

38:14

out. Like, no, that's like. It would work

38:16

fine if you're descending over normal

38:19

terrain, or if you're getting too low and you

38:21

know, flat. I think even if you're over

38:24

certain kinds of mountainous terrain, but I believe it

38:26

was a specific layout of these kinds of

38:28

this kind of mountainous terrain that was causing it

38:30

problems. Like there were lots of little peaks that

38:33

they were flying over that were triggering it. And

38:35

just because of a flaw in the system, it just wasn't sounding because

38:37

planes run into mountains. You're

38:40

right. Planes and mountains don't mix. It

38:43

just, that's like a really bad.

38:45

Blah. Yeah. Nowadays

38:47

we have a more advanced ground proximity warning

38:49

system. I think we've talked about this in the past. It's called enhanced

38:52

ground proximity warning system. EGP WS.

38:55

That fixes these flaws. So this doesn't

38:57

happen anymore. Is it like it can't handle

38:59

it when it changes that much?

39:01

The reports that

39:04

I saw didn't really dive too much into

39:06

what the flaw was. I think it was probably a very technical

39:09

thing that they didn't want to really dive into super much.

39:12

Okay. But yeah, just all you have to know is that over

39:14

this kind of mountainous terrain, it just wasn't sounding.

39:16

All of this to say

39:17

the aircraft was in controlled flight until it hit the

39:20

trees at the top of the ridge. So

39:22

this is what's categorized as controlled flight

39:24

into terrain. And that just means

39:26

the plane was fine. The plane was flying the way

39:28

it showed up. It was controlled and they just

39:30

flew into the terrain.

39:32

Even though the condition of the wreckage didn't allow for

39:34

complete examination of the flight control systems, the

39:36

flight data recorder showed the aircraft was being

39:38

maneuvered up to its initial right-hand wing

39:40

impact with the tree.

39:42

So from this and the distribution of the aircraft parts, it

39:44

included that the aircraft was structurally intact

39:46

up to the initial impact.

39:48

Flight data recorder also showed engines

39:50

were operating at the time of the impact.

39:52

Therefore loss of power was not a contributing factor.

39:54

It was all that the plane was working fine. There

39:57

was no, there was no mechanical reason

39:59

for that. this to have happened.

40:01

So I'm gonna go through some of the findings from

40:04

the report here.

40:05

The aircraft was structurally intact prior to initial

40:07

impact with TREE.

40:08

And we know that's one thing we've talked about quite a bit.

40:10

You know, it's when the investigators first arrived, they

40:13

tried to see like how big the debris field is, where

40:15

is everything, like to determine whether

40:17

the plane broke apart in the air or if it was in

40:19

one piece when it hit the ground. So it was intact

40:22

when it hit the TREE. And the engines were still operating

40:24

normally at the time of impact.

40:26

Perfectly fine plane.

40:27

Polonia airport was operated with total

40:30

number of air traffic control personnel on duty below

40:32

requirement. So there weren't as many air

40:35

traffic controllers as there should have been.

40:36

The ongoing training for controller, especially

40:39

in critical situation emergency procedures was

40:41

insufficient.

40:42

Air traffic controller needed better training.

40:44

Yeah, sounds like it.

40:46

Opposite runway operation was common practice

40:48

for takeoff and landing at Polonia airport

40:50

and presented a safety hazard for air traffic

40:52

operations. Like I said, this was unusual

40:55

that one plane was taking off in one direction and

40:57

this plane was coming in to land on the other one. That's

40:59

really unusual, but they did it at this airport.

41:02

The runway was not closed for landing when

41:04

visibility was only 500 meters as

41:06

compared to the weather minima of 800 meters as

41:09

stated in the regulation dated January

41:11

19th, 1996. That's

41:13

the thing you focused on right away. Like

41:15

they

41:15

should have closed it. There's

41:17

not enough visibility. They should not be landing.

41:20

The dispatcher did not discuss the weather condition

41:22

at destination with the flight crew.

41:24

The use of same digits on flight numbers, especially

41:26

for flights in the same area presented a safety

41:28

hazard for flight operations. Probably something

41:31

you don't think about. You never thought about before this episode.

41:34

Having similar flight numbers can be a

41:36

safety problem. How are flight numbers

41:38

determined? How

41:42

could they be like the same plane

41:44

with the same flight number or two

41:46

different planes with the same flight number at the same time? Like

41:48

that just seems bad. Yeah,

41:50

you know, I don't know enough about that to

41:53

really give you an answer. Maybe that's something we

41:55

can explore in one of our supplemental episodes at

41:58

the end of this batch. Okay.

42:00

Yeah, I'm gonna say we're gonna do that, but maybe

42:02

we can. Yeah, cuz I

42:04

really don't know enough about that.

42:05

The approach controllers instruction for Indonesia 152 to

42:08

intercept ILS was incomplete in which the

42:10

phrase From the right side was not mentioned.

42:13

The complete instruction was transmitted earlier

42:15

But with the call sign Mripati 152 instead

42:17

of Indonesia 152. So again, from

42:19

the right side that little phrase could

42:21

potentially have stopped this. The flight crew

42:23

did not rigorously comply with the company's standard

42:26

operating procedure for the management of altitude

42:28

change.

42:29

The flight crew deviated from procedures

42:31

that required when the autopilot is engaged.

42:34

Okay, this is remember we were asking earlier like

42:36

why how could they put 200 instead of 2000?

42:39

How did no one notice? Yeah, and I said

42:41

we're gonna talk about it later. This is what we're talking about it.

42:44

So the crew didn't

42:46

do what they should have done when it came time

42:48

to change altitude. The actual procedure

42:51

that should be followed is when the autopilot

42:53

is engaged Pilot flying is to make

42:55

changes to the autopilot settings and announces

42:57

flight mode annunciator.

42:59

Pilot not flying confirms changes

43:01

made by pilot flying and to announce mode

43:03

changes on his flight mode annunciator.

43:06

Pilot not flying to call when approaching assigned

43:08

altitudes like 1000 feet to go.

43:11

So they didn't follow

43:13

that. Normally one pilot changes

43:15

it says what he did and the other pilot double

43:17

checks it. Looks and says yes, you did

43:19

it and also verbalizes it. But in

43:22

this case, you know, the pilot was or the

43:24

captain was making changes. He was asking the first officer

43:26

to look at the air conditioner and like distracting him with

43:28

other tasks instead of having this checks

43:30

and balances system like the way it's supposed to be.

43:33

And also, you know, the pilot

43:35

not flying is supposed to be watching that altitude

43:37

and calling out when they're getting to

43:39

their assigned altitudes. It's a lot

43:41

for one person to do. So that's why

43:44

you know, they want to divide these tasks and have someone

43:46

double checking. The aircraft turned to

43:48

the left instead of to the right by pilot flying,

43:51

even though the instruction was given and was correctly

43:53

read back in radio communication with the air

43:55

traffic control.

43:56

The pilot flying's instruction to check that

43:58

cockpit air conditioning had to. distracted pilot

44:00

not flying's attention

44:02

and added the crew's workload at

44:04

a crucial point in time, presumably causing the pilot

44:06

not flying to not immediately identify

44:08

the aircraft was turning to the left instead of to the right

44:10

as instructed by air traffic control.

44:12

We've talked about before how there's

44:14

nowadays there's strict rules about

44:17

the pilots talking when they're

44:19

getting ready to land. There's like what they call sterile cockpit

44:22

where they're only allowed to talk about things

44:25

related to the flight and the safety

44:27

of the flight

44:28

below certain altitudes, you know, presumably when

44:30

coming in to land and when doing their first takeoff

44:32

for safety reasons. So stuff like this doesn't happen. So

44:34

they're not having some other conversation

44:36

or there's not something else going on. It's like,

44:39

no, we're going to focus on

44:40

this because this is the most dangerous time

44:42

for us. And yeah, they're being

44:44

hot. Uncomfortable. I get it.

44:47

But yeah, you're going to be, you're about to land, right? If

44:49

you're hot, you're three or four minutes

44:51

away from landing. Just deal with it.

44:54

I say that also as someone who flies without

44:56

air conditioner in Austin in

44:59

the summer. So I'm used to dealing with

45:01

with it being pretty hot. The radar return rate

45:03

on the screen, which is at 12 seconds interval is

45:05

sufficient for en route, but insufficient for approach.

45:08

So that's to say this slow radar is

45:10

fine when you're tracking a plane that's

45:12

like a cruising altitude when it's en route

45:15

between destinations. But when it's on approach

45:17

coming into land, it needs to update much faster.

45:19

Yeah,

45:19

it makes sense because yeah,

45:21

that's so slow. Mm-hmm.

45:25

The approach controller did not issue position updates to the crew

45:27

when the flight track appeared to be near an obstacle

45:30

and outside the localizer vectoring footprint

45:32

boundary. So maybe

45:35

it's because the updates were too slow

45:37

or who

45:38

know, maybe the controller was distracted,

45:40

but

45:41

he didn't give them a warning or

45:43

when the flight appeared to be not

45:45

going in the right direction more quickly. The

45:48

approach controller did not react as the transponder

45:50

mode C returns on his radar screen indicated

45:52

the aircraft had descended below 2000 feet altitude. There

45:55

was a lack of situational awareness of the pilot

45:57

flying regarding the aircraft's position and projected

45:59

for the flight.

45:59

flight path, which started from initial

46:02

radar vector. So normally, when you're

46:04

coming in and you're doing these instrument approaches, you

46:06

have, and we've talked about this before, you have what they call a

46:08

plate. And it's like a diagram showing

46:11

the airport, shows all the different waypoints

46:13

and how you're going to come in and how you're going to land, what direction

46:15

you're going to turn, what heading you need to be on.

46:17

And perhaps because they came in

46:20

on the south side instead of the north side like you expected, they

46:22

just kind of, the pilot flying kind of just lost

46:24

track of where he was in, you know, in

46:27

relation to the airport. It's frustrating

46:29

or not. I don't know, but just there's so many little

46:32

like, oh, this, this, this, like little things.

46:34

It just sounds like that.

46:35

A lot of it, both everyone was a little

46:37

off.

46:38

Yeah. And that's, that's why I find, that's why

46:40

we started this podcast. That's why

46:42

I find this so interesting. It's like, it's never, well, it's

46:44

rarely ever like, oh my God, here's the one smoking

46:46

gun that caused everything. It's like, well, now first, this

46:49

happened, which led to this thing happening,

46:51

which led to this thing, you know, and you just work your way

46:53

down. It's like all of these things had to line up in the

46:55

exact wrong way to cause this. There's only

46:57

the one smoking. There was that one episode where there was

46:59

one smoking gun. There was that

47:03

good memory, Chris.

47:05

The flight crews focused attention on horizontal

47:07

position may have degraded their altitude awareness.

47:09

Again, they were fixated on their heading and which direction to

47:12

turn. And they stopped looking at their altitude

47:14

or they didn't notice it as fast.

47:16

The aircraft did not capture 2000 foot altitude

47:19

for reasons that could not be determined.

47:21

The most probable cause for the autopilot not

47:23

capturing 2000 foot altitude is incorrect

47:26

altitude setting. Remember you asked earlier, like how

47:28

did this happen? The report can't

47:30

say definitively that the pilot

47:33

put the wrong altitude in, but it's

47:35

speculating that that's most likely what happened.

47:37

The report actually goes on to say an autopilot

47:40

capture malfunction is possible, but not probable.

47:42

They did the odds on it

47:44

and the failure rate of

47:46

this happening, like the odds that

47:48

it would fail and it would cause this to happen is

47:51

about one in two billion.

47:53

So for the

47:55

sake of this podcast, let's rule that out. Yeah.

47:57

But that being said, we have talked about things before.

47:59

where it's like astronomical odds,

48:02

but it happened. Like when the thrust reverser deployed

48:04

in that one Brazilian flight, you're like, yeah,

48:07

this is like a one in 6 billion thing, but it happened.

48:10

It doesn't mean it's impossible, but it means

48:12

it's

48:12

crazy improbable. The

48:15

flight data recorder recorded the ground proximity

48:17

warning system warning was on

48:19

for five samples. Given the sampling

48:21

rate, the duration of this warning was between four and

48:23

six seconds. And there was no evidence

48:26

on the cockpit voice recorder recording that

48:28

ground proximity warning system oral warning

48:30

was produced before the aircraft's impact

48:32

with the tree for reasons that could not be determined.

48:34

Again, this is just

48:36

the ground proximity warning system warned and

48:39

it says it activated five times,

48:41

but it was never heard in the cockpit voice

48:43

recorder. So presumably it never went off. That's

48:46

crazy. Yeah, awful. That's

48:48

maybe one of the reasons that we now have enhanced ground

48:50

proximity warning system. They also nowadays,

48:53

more modern, they also incorporate GPS

48:56

into the ground proximity warning system so

48:59

that it knows

49:00

where the terrain is and where you are in relation

49:02

to it. So it

49:04

can kind of keep track of that a lot better in real time.

49:07

And we've talked about that before, about databases and how they

49:09

need to be updated. Yeah. Oh yeah,

49:11

yeah.

49:12

Because terrain,

49:13

even

49:15

though terrain may not change, there may be towers

49:17

and buildings and stuff. So all

49:20

this to wrap up, there was confusion

49:22

regarding the turning direction of left turn

49:24

instead of right turn during radar

49:27

victory that reduced the flight crew's vertical awareness

49:29

while they were concentrating on the aircraft's lateral changes.

49:32

You're getting their fixated on fixing one thing. Another

49:34

thing slips away.

49:36

This caused the aircraft to continue descending below

49:38

the assigned altitude of 2000 feet

49:40

and hit tree tops at 1550 feet above mean sea level.

49:44

That's like

49:45

the quick summary of everything.

49:48

We've talked about this before. I got my pilot

49:50

license last year and I've been working on

49:52

getting an instrument rating, which would allow me

49:54

to do instrument flying like this, do

49:56

ILS approaches. So I'm a little familiar with

49:58

these things.

49:59

And in training,

50:02

the instructor always tells me, like, if there's

50:04

one thing that's wrong,

50:05

you don't fixate on it. He's like, you

50:08

know, like hit my hands. It's like, well, if there's

50:11

one thing off, you do something

50:13

to begin trying to fix that

50:15

and then continue scanning and make sure everything else

50:17

is okay. Because, and he always tells me this, if

50:19

you keep staring at that one thing, you're not looking

50:22

at everything else. And something else, other

50:24

things are gonna slip away. It's like, so begin

50:26

your fix and then come back to

50:28

it and see if it's fixed. And

50:30

we've talked about that,

50:32

like the light being out

50:34

or like, and then running out of gas.

50:37

Right, yeah, so yeah, you get fixated on one thing

50:40

and then everything else falls apart and

50:42

it's just entirely preventable.

50:45

But yeah, that's it, that's Gerudo 152, a

50:48

really bizarre mix up of left turn

50:50

versus right turn

50:51

and just losing track of where you are in

50:54

space. Did they, like,

50:56

who is more, like,

50:59

I mean, the pilot, like?

51:01

So the investigation laid blame on

51:03

both the air traffic controller for, or

51:06

I guess lack of training with the air traffic controller.

51:09

It also laid blame with the airline

51:11

and their training for pilots. There

51:13

was potentially, the investigation digs

51:15

into this a bit more. We didn't really cover this in

51:17

our talking about it, but saying that

51:20

when training pilots,

51:23

the training devices or the training systems

51:26

have digital navigation displays, while

51:28

some of the planes they fly are flown

51:30

with analog equipment, which are both fine

51:32

for instrument approaches, but that the captain

51:34

may have been overwhelmed due to his lack of

51:37

familiarity with analog instruments, which

51:39

may have put him a little behind the plane.

51:42

So it does split blame

51:44

here on top, and I'm just saying that's not the only

51:46

thing they found. That's on top of everything else we've talked

51:48

about here.

51:49

And of course, they also

51:51

talk about the failure of the ground proximity warning

51:53

system. And

51:55

there were lawsuits as a result of this accident.

51:58

And the lawsuits were filed.

51:59

against the manufacturer

52:02

of the ground proximity warning system. Interesting.

52:04

I get that. But also, it seems

52:06

like not just them.

52:09

I think that

52:10

it may have been complicated because the lawsuits were

52:13

filed on behalf of American

52:15

passengers and as

52:17

an American,

52:19

how do you file a lawsuit against

52:22

a foreign airline that's flying

52:24

a domestic route? Like the US court doesn't

52:26

have jurisdiction over that. So I think this was

52:29

their

52:29

roundabout, right? It's like, oh, well, we can't

52:32

sue them because the US court has no

52:34

jurisdiction there, so we'll sue the GPWS

52:36

manufacturer.

52:38

Does that make sense? Yeah, it does. Though

52:40

you can't sue people who are in another country.

52:43

Well,

52:43

what's what's the US court jurisdiction

52:46

about a domestic flight operated

52:48

by a government owned airline in another country?

52:51

Yeah, government owned.

52:52

It just gets really complicated. Yeah, yeah.

52:55

So the plaintiffs allege that the ground

52:57

proximity warning system was defectively

52:59

designed, I guess, and that the manufacturer

53:02

knew about this for some time and

53:04

had the system worked as it was supposed to. The accident

53:06

would have been

53:07

avoided. Of course, it was a huge back and

53:09

forth thing, and it

53:11

dragged on for six years. And eventually

53:13

the lawsuit was settled out of court.

53:15

Yeah. So I guess there's a lot of blame

53:17

to go around. I don't know who I would. I

53:20

can't just say this person

53:22

or this entity is responsible for it.

53:25

It just kind of was all over the place. Which

53:27

is which goes to the messy like the

53:29

craziness of this one.

53:31

Yeah, they call it like the Swiss cheese model, like

53:33

lining up a bunch of slices of Swiss cheese like what are

53:35

the odds that there's going to be a hole that goes all the way through, right?

53:38

Yeah.

53:38

But yeah, that's it for Gerudo 152.

53:41

Just really frustrating one. I know we

53:43

have some sometimes where we say that this is just like one

53:45

of the super frustrating episodes. I'm not

53:47

sure I'm going to do a real quick list

53:49

of everything I can think of. OK, what do

53:52

you mean? Like if things went wrong? Yeah. Force fire

53:54

smoke shouldn't have been called

53:56

the wrong sign or wrong. They're

53:58

like turn the wrong direction.

53:59

and had the wrong minimum altitude,

54:02

confusion about what direction they were turning, like

54:05

who's on first, the Jeep, the

54:07

ground proximity warning not working,

54:09

an abnormal approach.

54:12

Right, and slow radar. Oh, and slow

54:14

radar. If any one of those things

54:17

had been different, maybe this could have been avoided.

54:19

So many, so many things. They

54:21

all line up to cause this. Probably still missed one. Maybe.

54:25

All right, but that's it. We'll be back next week with another

54:28

episode. Thank you, everyone.

54:30

All right, bye.