reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2007 B737 over-run Yogyakarta Indonesia

Brief account : 

The B 737-400 landed long and fast after an extremely unstable approach in day VMC conditions. It over-ran the runway end at high speed.  The Captain had ignored multiple GPWS alerts and go-around calls from the F/O. 

Crew-related factors : 

The 45 year old Captain had 13,500 hours; the F/O was 31 and had 1500 hours.  In this event, the Captain had given a detailed brief for an ILS approach, in which each point was acknowledged by the F/O.

However the aircraft was then cleared for a visual final. The Captain realised the aircraft was high and fast, with a tailwind, but did not use the speed brakes at this point.  He attempted to dive off the altitude and called for flaps but the F/O did not extend them as the speed was significantly above the limit speed. At 10 miles the aircraft was 1400 ft too high and at 283 kts. With a high descent rate the GPWS sounded several times and the F/O called for a go-around. The aircraft touched down with a high G 260m passed the target touchdown point and almost 100 kts too fast.    

The report considered that the Captain had become totally fixated on landing. It noted "The PIC informed the investigation that he had decided to land the aircraft from the approach, despite the aircraft being in an unstabilized condition; specifically, not being configured for the landing; the flaps at 5 degree position; the GPWS sounding alerts and warnings; and the copilot not confirming the completion of the landing checklist; rather, calling for a go-around. The PIC persisted with the approach and landing. The copilot did not attempt to take control of the aircraft from the PIC and execute a go-around, in accordance with company instructions that require taking over when an unsafe condition exists."

Even if the crew procedure were to use PicMA on all normal instrument approaches, the Captain's attitude was such that a hazardous approach might have been continued: given that it was VMC, he might well have taken control early even if the approach was not going to be stabilised by the appropriate "gates". However,

1) the briefing would have been more interactive, rather than just the F/O saying "check" several times;

2) the F/O would probably have been more conservative in the approach planning;

3) the Captain would likely have intervened to enforce an adjustment to the profile far earlier on; 

4) from an overall point of view, the F/O would have accumulated more valuable handling experience during his line flying and been more confident in asserting himself when he detected the need for corrective action.

Type: 
B737-400
Where: 
Yogyakarta Indonesiax
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2007
Deterioration: 
No
Vert Guidance: 
None
Both Head Up: 
Yes
LoC: 
No
Fully prepared: 
Yes
Actual Weather: 
None relevant
CCAG: 
High