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00:00Dramatic video captures a scene of chaos.
00:04You've got this trail of people coming away from the aeroplane.
00:08It was raw, unedited.
00:11A crash survivor records the desperate escape
00:14from the wreckage of Garuda Flight 200.
00:18Huge explosions going off, big plumes of black smoke.
00:23What sent the Indonesian airliner careening off the runway?
00:28We don't deal in speculation. We want facts.
00:32There was intense pressure to deliver.
00:35Investigators must accept a shocking explanation for the crash.
00:40It's very hard to understand.
00:42Go around the cockpit. Go around.
00:45I'd never heard anything like this.
00:50Hey, hey.
00:59It's early morning on the Indonesian island of Java.
01:08Garuda 200 cleared for descent. Runway 0-9.
01:12Garuda 200 cleared for descent. Runway 0-9.
01:16Garuda 200 cleared for descent. Runway 0-9.
01:20Garuda 200 cleared for descent. Runway 0-9.
01:24Garuda 200 cleared for descent. Runway 0-9.
01:28Surface wind is calm. Visibility is 8 kilometres.
01:33A Boeing 737 flies high overhead.
01:37Copy that. Runway 0-9.
01:39Wind's calm. Visibility 8 kilometres.
01:4427,000 feet.
01:4627,000.
01:48The crew of Garuda Flight 200 is getting ready to land.
01:53All right, you can go ahead and proceed with the landing checklist.
01:56Landing lights on.
01:59Approach frequencies check.
02:02Indonesia is made up of 18,300 islands,
02:07so air travel is incredibly important.
02:10Garuda is critical to the aviation infrastructure.
02:15Fasten seat belt light is on.
02:19There are 133 passengers in the cabin.
02:24They're nearing the end of a short flight
02:27from the Indonesian capital of Jakarta,
02:30265 miles southeast to the city of Yogyakarta.
02:36Most of the passengers are Indonesian,
02:39but there's also a group of Australian journalists.
02:43They're covering a state visit by Australia's foreign minister
02:47who's travelling on another plane.
02:50Relationship between Australia and Indonesia are often strained,
02:54so whenever a minister or head of state visits that country,
02:58there's a heightened interest from the media,
03:02and so we had a large media contingent following.
03:06Kyle Quinlan is also headed to Yogyakarta.
03:09Kyle Quinlan is also headed to Yogyakarta.
03:12He's an Air Force security officer,
03:15part of the foreign minister's advanced security team.
03:20I was working for 34 VIP squadron.
03:23They're the guys who look after security for the prime minister,
03:26heads of government, stuff like that.
03:28We had to travel internally on civilian aircraft.
03:32The plane is about 15 minutes from touchdown.
03:37Speed is 320 knots.
03:40OK, when we're cleared, we approach runway 9, course 088.
03:46Captain Mohammed Marwota Kumar has been with Garuda for 21 years.
03:53Approach flaps 40, autobrake 2.
03:58With airspeed approximately 141 knots.
04:01On landing, parking stand to the left.
04:04As they near the airport, he briefs First Officer Gagam Raikman
04:08on the final steps needed to get their plane on the ground.
04:15Understood.
04:17Approach briefing complete.
04:19This was a typical day out for these pilots.
04:22The captain was very experienced, the co-pilot a little bit less experienced,
04:26but certainly just another day at the office.
04:29A short flight, easy.
04:35Enough slack and it's time to get back at it.
04:39Yes, sir. No life like it.
04:42For Quinlan, the flight's been a welcome break from a hectic schedule.
04:47We'd just come off a 16-hour shift the night before.
04:50We had probably about three hours sleep,
04:52so it was kick back and just relax and just enjoy this time
04:56before we get on the ground and before we have to work.
05:00The plane is less than 15 miles from the airport.
05:05Whoa, strong wind.
05:07They hit some slight turbulence.
05:10What will challenge you in tropical latitudes close to the equator
05:14is the fact that the weather there has a greater exchange of heat
05:18and therefore you're going to get more wild winds.
05:21And you're going to have to be very careful
05:23and you're going to have to be very careful
05:26and therefore you're going to get more wild winds.
05:29And you've got to be on your toes as a pilot.
05:34Garuda 2-0-0, you're clear to approach runway 0-9-er.
05:38Let me know when you have the runway in sight.
05:41Copy that.
05:44The bumpy ride doesn't alarm the experienced captain.
05:48Flaps one.
05:50He continues with the landing approach.
05:52Flaps one.
05:55And calls for the flaps to be extended.
05:59Flaps increase the wing's surface area,
06:02adding the crucial extra lift needed at slower speeds.
06:07Gear down.
06:10Gear down.
06:12Gear down.
06:23They're now less than 3,000 feet above the runway.
06:28Flaps 15.
06:31You're in this position of taking this big bird
06:33and putting it into a slow enough airspeed
06:36with enough configuration on flaps and landing gear and so on
06:39that you're a little bit vulnerable.
06:43As the plane descends, Quinlan begins to feel uneasy.
06:48His Air Force training tells him something's not right.
06:52When you travel on aircraft so frequent,
06:54you become aware of your surroundings
06:56and for me it was when we were just standing
06:58and looking out the window and thinking,
07:00we're not supposed to be at this height,
07:02for how fast we were going.
07:03Something's off, huh?
07:09Gear to land, two miles out.
07:13Quinlan can't shake the feeling the plane's dropping too fast.
07:17When I realised something really bad was going to happen,
07:20I turned to my boss and I said...
07:22We're going in.
07:24OK, then.
07:37What can you do? You're stuck here, you know?
07:39There's nothing that you can do except for tighten up the seatbelt
07:42and just hang on and just ride this out
07:44and hopefully we make it, you know?
07:52Go around, Captain. Go around.
08:05We landed and we bounced.
08:10It's chaos as the plane bounces a second time.
08:15And I just remember thinking, just hang on, hang on, hang on.
08:26Then a third impact and the plane isn't stopping.
08:29We're scraping on the belly.
08:31I can hear the wings, the engines, everything.
08:40Then probably the biggest impact I've ever had in my life
08:43was when we hit that embankment.
08:51Emergency crews race towards the crash site.
08:55But the 737 has careened off the runway into a swampy rice field.
09:00Getting vehicles to the site won't be easy.
09:03When you've got a crash that occurs in the middle of an airport
09:06where there's plenty of access, it's one thing.
09:08But when it's out off the airport site,
09:10in this particular case in a rice paddy,
09:12very limited access,
09:14it gets almost exponentially more difficult.
09:22Many passengers are badly injured and fire is spreading fast.
09:26But it's not as bad as it looks.
09:28Many passengers are badly injured and fire is spreading fast.
09:33Kyle Quinlan realises there's no time to wait for rescue.
09:37Once we pulled up, I was still operating
09:39and to see so many people who were busted up and couldn't do anything,
09:43I needed to do something and help these people out.
09:48Inside the burning fuselage of Garuda Flight 200,
09:51Kyle Quinlan struggles to get out.
09:55Fire is blocking the nearest exits.
09:57The whole plane, there's all just the glow and the heat
10:00coming from the right side of the aircraft.
10:04If the fuel tanks ignite, the plane could explode.
10:07But firefighters can't reach the crash.
10:10Firefighters can't reach the crash.
10:12Firefighters can't reach the crash.
10:14But firefighters can't reach the crash.
10:17Any time you've got the possibility of fuel,
10:19you need fire suppression right there, right now,
10:22because you've got massive flames at 1,800 degrees.
10:25You've got a lethal situation.
10:29Quinlan still can't get out.
10:32Turn to my left, jump across, grab the emergency exit
10:35with another Indonesian guy and crack the emergency exit.
10:40Passengers scramble out of the door.
10:43People are climbing over each other,
10:45and it was a pretty wild scene.
10:51Sir, we've got to get you out of here, now!
10:54Quinlan's sergeant, Michael Hatton,
10:56is too badly hurt to get off the plane without help.
10:59He was unconscious and falling in and out of consciousness,
11:03so I carried him out, jumped off the left wing tip
11:06into a rice paddy,
11:08and then so he sank up to sort of knee-deep in water,
11:11about 100 metres away from the aircraft, as a hut.
11:15I just grabbed my boss and carried him there.
11:18I'm all right here. I'm all right.
11:20I just can't...
11:22Are you all right here?
11:24I can see his injuries. They're not life-threatening.
11:27He said, look, you'll be right here.
11:29I'm coming back for you. You'll be right.
11:32I'm coming back.
11:37Off I went and went back to the plane.
11:41Freelance cameraman Wayne Sukada also makes his way off the plane.
11:47He soon begins capturing dramatic images of the aftermath.
11:52We've got the cameraman grasping for breath.
11:55We've got him staggering around, away from the aeroplane,
11:58filming as he went.
12:02And you've got this trail of people coming away from the aeroplane.
12:06It was raw, unedited.
12:10And it was a real sense of being there.
12:18The fire and the intensity, it was massive, you know?
12:22Like, this thing was...
12:24Huge explosions going off.
12:26Big plumes of black smoke.
12:29Just how the aircraft was burning, it was just phenomenal.
12:33Like, I've never seen anything like it.
12:35Back on board the plane,
12:37Quinlan helps more passengers escape a cabin
12:40that's fast becoming an inferno.
12:43A lot of people were not in a condition to be able to do anything,
12:47so I'm in a condition where I can assist.
12:49I'm going to assist. I'm going to do the best I can and help, you know?
12:55The scene was one of chaos.
12:57On one hand, you've got lots of officials not knowing what to do.
13:01On the other side, you've got passengers
13:03almost looking after themselves and rescuing each other,
13:06coming away from the wreck.
13:08You've got emergency services who can't get to the aeroplane
13:11because of the terrain, because of the ditches and the rice paddies.
13:15It really was chaotic.
13:19Of the 140 passengers and crew on board,
13:2221 people have been killed.
13:25Clearly, you knew that people were not going to survive this.
13:29It's almost a miracle that so many did survive.
13:37Sukada keeps rolling as crash survivors,
13:40including Kyle Quinlan and Michael Hatton,
13:43arrive at a nearby hospital.
13:47Australian Air Force. Air Force.
13:49There was just stretches and everyone over the floor, you know,
13:53and it was just a big shock to me.
13:56Just so many people.
14:00Within hours, Sukada's dramatic footage is broadcast around the world.
14:07The public response to that footage was overwhelming.
14:10Millions and millions of hits on YouTube.
14:13Television stations around the globe picked it up
14:16and it was repeated continuously for days after the crash.
14:23At the crash site, investigators from Indonesia's
14:26National Transportation Safety Committee, or NTSC,
14:30face the enormous task of piecing together what went wrong.
14:35Aircraft debris is spread all along the plane's deadly trajectory,
14:40from the runway to where it came to rest in the rice field.
14:44An airplane is basically an aluminium eggshell.
14:49It is incredibly strong when it's used the way it's designed to be used.
14:53But if you skid it off a runway at high speed,
14:56it's not going to stay together.
14:59Alan Stray of the Australian Transport Safety Bureau
15:02joins the investigation.
15:04What have you got so far?
15:06We have to establish where did it touch down?
15:09Were there any runway marks?
15:11Did it bounce? Did it skid?
15:14What are the distinguishing features on the runway
15:17that may help us build a picture
15:19of what was happening at the time of the accident?
15:22Let's get the full team out to runway nine.
15:25Stray knows that the relatives of the dead
15:28are already demanding answers.
15:32Because there were so many international people
15:35on board this aircraft, some of whom had died,
15:38there was intense pressure to deliver.
15:44Investigators search for clues to explain
15:47why Garuda Flight 200 bounced off the runway and crashed.
15:51Looks like they hit pretty hard.
15:55They discover gouges
15:57and shattered pieces of landing gear on the runway,
16:00clear signs that the plane slammed down with unusual force.
16:06The nose wheel digging in and fracturing
16:10was indicative of a very hard G-force on that impact.
16:18It's also clear the plane hit the runway more than once.
16:22More skid marks here.
16:24The idea of walking the site
16:26is to establish a sequence of the events.
16:30First impact here.
16:32Being very careful not to disturb any perishable evidence.
16:36So, one, two, three,
16:40then off the end of the runway.
16:44There was a lot of questioning
16:47and trying to establish why did the aircraft bounce?
16:53Hang on a minute.
16:55The location of the first skid mark
16:57gives investigators a crucial lead.
17:01How far are we from the threshold of the runway?
17:06860 metres.
17:08Yikes, that's more than a third of the runway.
17:11It landed long, it didn't touch down until a long way into the runway.
17:15The distance of the touchdown from the threshold
17:18raised serious questions in the minds of the investigators.
17:24So, it comes in long, it hits hard and bounce.
17:31Let's gather up as much weather data as we can.
17:34We're very keen to establish, was there a weather situation,
17:39a wind or a downdraft, a strong tailwind?
17:43Stray suspects wind shear might explain what he sees.
17:47Like this and like this.
17:50Wind shear can produce violent updrafts and downdrafts
17:54that are impossible to fly through.
17:56Close to the ground, it can be deadly.
18:00Especially in the age of climate change,
18:03we've got more and more violent winds,
18:05gust fronts, downdrafts, things of this nature,
18:08and sometimes microbursts.
18:10Investigators check with tower controllers
18:13to find out what kind of weather the pilots were facing
18:16as they descended toward the airport.
18:18Here, take a look.
18:20Surface winds were completely calm.
18:23The weather data shows there were strong winds at high altitudes.
18:29But the winds near the runway were calm.
18:32There's no sign of the kind of downdrafts
18:35that could force a plane to the ground.
18:37That wind tapered right off
18:39and there was ample time for the crew to establish the aircraft
18:44in a stabilised approach from 1,000 feet.
18:49Indonesian police launch a criminal investigation into the accident.
18:56They bring the captain in for questioning.
18:59For crash investigators, the move has unfortunate consequences.
19:05I really have nothing more to say.
19:08I'm sorry.
19:09In cases where the investigation becomes criminalised,
19:13and particularly when that happens early on,
19:15if we have police involved or lawyers involved...
19:19We did everything by the book.
19:21..that can intimidate people
19:23and it can lead to them not cooperating effectively with investigators.
19:28With the flight crew under criminal suspicion and reluctant to talk,
19:32investigators must look for other leads.
19:37Downloading the plane's black boxes, or flight recorders,
19:40is now a top priority.
19:42Investigators quickly recover them from the wreckage
19:45and send them for analysis.
19:47All right, let's get these into the lab.
19:50The flight recorders are vitally important.
19:52It's important to get as much information from them,
19:55early information,
19:57so that it may direct the thrust of the investigation.
20:02Without that data, we're screwed.
20:04Meanwhile, investigators focus their attention on the crash site.
20:09Every detail is a possible clue.
20:11What I want to know is why they didn't stop at the end of this runway.
20:17The investigation was initially concerned about the touchdown point
20:21and the remaining distance on the runway.
20:25Is that the runway map?
20:26They wonder if, after coming in long,
20:29the plane simply didn't have enough runway left to stop safely.
20:34Even with a two or three mile runway,
20:36you've got a finite patch of concrete on which to land an airplane.
20:41He touched down here, 860 meters from the threshold.
20:47Now that gives him just over 1,300 meters to stop.
20:51The runway in Yogyakarta is shorter
20:54than the runways at many other international airports.
20:57But even though the pilots touched down late,
21:00Stray calculates they still had enough room to stop their plane.
21:04He had more than enough runway.
21:07The length of the runway was completely adequate
21:10for a Boeing 737 landing.
21:14Investigators need to dig deeper.
21:17We need to know why this plane didn't slow down once it was on the ground.
21:21I want to take a close look at everything.
21:25They begin a painstaking analysis of the major mechanical systems on the 737.
21:31Especially those designed to help the plane slow down and stop on landing.
21:36Brakes, spoilers and thrust reversers.
21:41Was there a mechanical failure?
21:43Looking at the performance of the aircraft,
21:46was it physically possible for the aircraft to stop?
21:51The careful analysis of the plane's mechanical systems
21:54provides a potential breakthrough.
21:57I think we got something here.
22:01A review of the maintenance log for Garuda Flight 200
22:05turns up an intriguing lead.
22:08There had been a write-up on a couple of occasions
22:11of thrust reverser failure on one thrust reverser.
22:15The thrust reversers redirect the jet's engine exhaust forward
22:19to help the plane slow down on the runway.
22:23You've got to remember, it's not just a matter of kissing the wheels onto the ground,
22:26it's a matter of discipline.
22:28It's not just kissing the wheels onto the ground,
22:30it's a matter of dissipating a tremendous amount of energy,
22:33a tremendous amount of kinetic energy.
22:35How do you do that?
22:36Well, you do it with the friction between the tires and the runway,
22:39hopefully using anti-skid.
22:40You do it with reverse thrust.
22:46You're not stopping!
22:48No thrust reverser!
22:52Investigators wonder if a malfunctioning thrust reverser
22:55explains why the crew couldn't stop before they ran out of runway.
22:59Full break!
23:00At the end of the day, you still have to dissipate all that energy,
23:04and if you don't have enough room to do it, you're off the end.
23:14But it's another dead end.
23:16According to the maintenance records,
23:18the faulty thrust reverser was repaired before Flight 200 took off.
23:22Looks like they fixed it.
23:26That had been rectified prior to this flight departing from Jakarta,
23:31and so there was no paperwork evidence of a failure.
23:42Investigators are going to need another lead.
23:47We don't deal in speculation. We want facts.
23:52The facts so far are limited.
23:56The 737 careened into a rice field
23:59after slamming to the ground almost a third of the way down the runway.
24:06The question is, why?
24:09Was the plane configured properly?
24:12Perhaps there was something wrong with the wing flaps pilots rely on for landing.
24:17The flap system on a modern jetliner like a 737
24:21create greater lift, and that means that we can approach an airport,
24:24we can take off from an airport with a much lower and safer airspeed.
24:29The team scrutinizes the mechanical rods, or screw jacks, that move the flaps.
24:36We needed to look at the flap setting.
24:38What flap setting can we establish from the wreckage?
24:44We measured the screw jack extension to establish what the flap setting was.
24:51What they find is astonishing.
24:54It doesn't look like the flaps are all the way out.
24:56The screw jacks show a flap setting of just 5 degrees,
25:00not nearly enough for a safe landing.
25:03We just could not believe that the aircraft would have landed with only 5 degrees.
25:08To provide enough lift on landing,
25:10the flaps of a 737 are usually extended step by step,
25:14from zero all the way to 40 degrees,
25:17as the plane slows and descends towards the runway.
25:22It's hard to overstate the value of the flap systems on a modern jetliner.
25:28Investigators aren't sure how the flaps ended up at only 5 degrees.
25:33The flap mechanism was damaged in the crash and may have moved on impact.
25:39To be certain of how the flaps were set,
25:41they need to know what's on the flight recorders.
25:44We need that data from the black boxes.
25:51But some of that data is proving elusive.
25:54Australian technicians have been unable to download the cockpit voice recording.
25:59It's a huge blow.
26:01If you don't have access to the CVR for whatever reason,
26:05then it's very difficult to understand what went on in the cockpit.
26:10Desperate to hear what's on the device,
26:12investigators send it to the US manufacturer,
26:15hoping experts there can recover the recording.
26:18So steps were taken to hand carry the recorder to the factory,
26:23so that the data could be downloaded.
26:27Crash investigators are having better luck with the second black box,
26:31the flight data recorder.
26:33They've managed to download all of its stored information.
26:37We were able to get information about the flap settings,
26:40the speed on the approach, the thrust reverser deployment,
26:43the dynamics of the approach and landing itself.
26:48The data reveals the 737 was coming in for its landing blazingly fast.
26:55Flight 200 hit the ground at over 250 miles an hour,
27:00more than 100 miles an hour faster than normal.
27:04We're not stopping!
27:05This is a ridiculous amount of speed to approach an airport with,
27:09with the intent of landing.
27:12The plane's speed at impact is so fast,
27:15it bounces twice before skidding into the rice field.
27:20The speed of the aircraft on short final and on touchdown,
27:26so excessive, there was no way it was going to stop.
27:33But why did the pilots touch down on the runway
27:36at such a catastrophically high speed?
27:41Pull up the data for the flaps, would you please?
27:45There.
27:48The flaps were set for 5 degrees.
27:52Never more than 5 degrees.
27:55The data confirms what the screw jack suggested to investigators.
28:00The flaps on Flight 200's wings were in a bizarre position,
28:04one that is never used during landing.
28:07It's not operational procedure to land with flaps 5
28:10unless there is a jammed flap and it cannot be extended.
28:16Investigators are left with an alarming possibility,
28:20that the plane crashed because the pilots touched down
28:23without performing one of the most critical steps needed for any landing.
28:28To hear an airplane that has been in an accident
28:31because of overrunning the runway had a flap setting of only 5
28:34and a 737 is very disturbing.
28:37Why the crew failed to set their flaps properly remains a troubling question.
28:44Meanwhile, media reports erode public confidence in Garuda Indonesia Airways.
28:51The accident affected negatively Garuda's reputation,
28:55but they had had other problems in the past.
28:59In 2002, Garuda Flight 421 was forced to ditch in a small river
29:04after both engines flamed out.
29:08And in 1997, Garuda Flight 152 slammed into a ravine,
29:12killing all 234 people on board.
29:17Garuda's record at that stage was just a series of accidents and incidents
29:23with large numbers of people losing their lives.
29:29In the wake of this latest disaster,
29:31Garuda is banned from landing at any airport in the European Union.
29:39The fate of Indonesia's national airline could be at stake
29:43if investigators can't figure out what went wrong on board Garuda Flight 200.
29:53After a painstaking data recovery process,
29:56investigators can finally listen to the cockpit voice recording from Garuda Flight 200.
30:02Fortunately, the recorder specialists at the laboratory are a tenacious breed
30:07and they do not give up easily.
30:10But will the sounds captured in the cockpit shed light
30:13on the decisions and actions of the flight crew?
30:17OK, let's hear it.
30:20When we're cleared, we approach runway 9, course 088.
30:24Investigators listen as the crew discusses their plans for landing.
30:28What you're doing is listening for the atmosphere and the tone,
30:32the ambience, if you like, in the cockpit.
30:35Approach flaps 40, autobrake 2.
30:38With airspeed approximately 141 knots.
30:42On landing, parking stand to the left.
30:45Parking stand to the left.
30:48Now, they know they need 40 to land, but they only get 5.
30:53What's going on?
30:56Approach briefing complete.
31:01At first, there's no sign the crew is worried.
31:05The captain certainly doesn't sound stressed.
31:08Then, the first hint that something is going wrong.
31:13Looks like we're not going to hit the glide slope.
31:15The plane is too high for this distance from the airport.
31:19Better get down a little faster.
31:26To land smoothly, planes need to lose enough speed and altitude
31:30to descend gradually and meet the runway at a shallow angle.
31:37Flight 200 is much too high.
31:39OK, he's a bit behind, but it shouldn't be a problem yet.
31:45Stray compares the descent of Flight 200
31:47with the flight path they should have been flying.
31:51It is not unusual to be a little behind in terms of slowing down
31:55and especially in terms of descending.
31:57And sometimes you find yourself high and fast,
31:59and you've got to make a decision.
32:01He definitely has some work to do if he hopes to get on track.
32:05Check speed, flaps 15.
32:07Check speed, flaps 15.
32:10Flaps 5.
32:14The captain is calling for flaps 15.
32:17Why is he saying flaps 5?
32:19Flaps 15.
32:21Something is very wrong in this cockpit.
32:24Check speed, flaps 15.
32:26The captain repeatedly tells the first officer
32:28to increase the flaps to 15 degrees.
32:31But the first officer never moves them past 5 degrees.
32:35Flaps 15.
32:39It's like they're not even in the same cockpit.
32:43Landing demands precise crew coordination.
32:46But as they speed towards the runway,
32:48the captain and his first officer seem to be ignoring each other.
32:52There's a lot of evidence that this crew was not thinking it through.
32:55They weren't situationally aware.
32:57They weren't communicating.
33:00OK. First things first.
33:03Why did the first officer ignore the captain
33:06and leave the plane at flaps 5?
33:08It's very perplexing.
33:10If you've got professional pilots, we can make mistakes.
33:13But usually that's why we've got two people up there,
33:15so one catches the other.
33:19Investigators suspect the high speed at landing
33:23explains the first officer's decision
33:25not to increase the flap setting.
33:27Way too fast for flaps 15.
33:31Flaps can be damaged by excessive drag.
33:34And when the captain calls for flaps 15,
33:37the plane is speeding at over 250 knots.
33:40Much too fast to safely extend the flaps any further.
33:44Flaps 15.
33:48The plane is moving so quickly
33:50that wind drag could tear the flaps right off the wings
33:53if the flaps were to be extended.
33:56I can very well understand why the first officer
33:59did not comply on going to flaps 15.
34:02They're grossly over-speeding flaps 5.
34:05The first officer was exactly right in not putting them down.
34:09All right. They were moving too fast to deploy the flaps.
34:13But why didn't the first officer say something?
34:16Tell the captain to slow down.
34:19Slow down.
34:21Slow down.
34:23Slow down.
34:25One of the issues was that he didn't communicate his reasoning
34:29for not responding to those commands for flap 15.
34:34He didn't communicate that to the captain.
34:37When you take a pristine Monday morning quarterback look at this,
34:40regardless of airline, regardless of culture,
34:42it's very clear that the co-pilot should have said,
34:45Captain, I got the airplane.
34:47But what it tells me here is that this co-pilot
34:49did not feel that he could speak up one way or another.
34:53Even more bizarre, why didn't the captain react to the loud alarm
34:57sounding in the cockpit just moments before the first impact?
35:01Go around, captain. Go around.
35:04Landing checklist completed, right?
35:10It's a tough one to ignore.
35:12There's nothing subtle about it.
35:14The ground proximity warning is a clear signal to a pilot
35:18that he's flying dangerously low.
35:21There were 15 ground proximity alerts and warnings
35:25during that final stage of the approach.
35:28When a crew member hears that, there should be instant action.
35:33Instead of aborting the landing,
35:35the captain does something that baffles investigators.
35:39Go around, captain. Go around.
35:42Landing checklist completed, right?
35:44He asks the first officer if the landing checklist is complete.
35:49Landing checklist? I never heard anything like this.
35:55When the co-pilot called for the captain to go around
35:58and the captain responded, landing checklist complete,
36:01it was just something that we could not understand.
36:06I was appalled.
36:08This was industry worst practice for crew resource management.
36:12A pilot ignoring 15 warnings,
36:14ignoring two pleas by a co-pilot to go around,
36:18and landing 79 knots too fast.
36:21This was atrocious.
36:23For investigators, the question remains,
36:26why did the crew continue with a landing
36:28that was clearly heading for disaster?
36:34Personnel files reveal both Garuda pilots
36:37are fully licensed and certified.
36:41The captain in particular has many years of experience,
36:45but his dangerously fast landing attempt
36:48and the poor communication in the cockpit
36:51lead investigators to question the quality of the crew's training.
36:55So there was a much deeper look
36:58at what training had been provided to the crew.
37:03Weak situational awareness and coordination.
37:07Poor communication. Unstabilized approaches.
37:12A review of training records for the entire airline
37:15uncovers a disturbing detail.
37:18This is not the first Garuda crew
37:20to have problems with a routine landing.
37:24We noted that in 2001 an analysis had been conducted
37:29and there was a number of instances
37:32of unstabilized approaches or fast approaches by crews.
37:37The finding shines new light on what happened in Yogyakarta.
37:42Investigators may finally be zeroing in
37:45on the cause of the Garuda 200 disaster.
37:51Play that last bit again for me, would you please?
37:54Investigators believe Garuda's poor training record
37:57helps explain the deadly landing in Yogyakarta.
38:02High quality training for pilots is absolutely critical,
38:06especially when they face a crisis.
38:09It's one of the few things that can help a pilot
38:12avoid a strange psychological phenomenon known as fixation.
38:17Fixation is when we are focused on completing a task
38:23to the exclusion of other things that may be going on around us.
38:27When you see people as egregiously ignoring
38:30all the warnings and the systems and the bells
38:33and the airspeed and everything else here,
38:36you've got people who are fixated.
38:38Nothing was getting through to this guy.
38:40Investigators theorize that the captain was so fixated
38:44on descending to the proper altitude
38:46that he didn't notice his speed.
38:48And even when the alarms sounded,
38:50he failed to realize that his plane was in grave danger.
38:57It's hard to imagine how somebody could get to that point,
39:00but we have a lot of flaws, and part of the flaw
39:03in the case of a pilot fixating on a runway
39:06is that he or she can blank out the rest of the advice,
39:09the ground proximity warning system, everything.
39:12Training helps combat fixation
39:15by reinforcing standard procedures
39:18designed to ensure pilots can break the spell
39:21and take in the information they need.
39:25Go around, Captain. Go around.
39:31Go around!
39:33Landing checklist completed, right?
39:35Better training might also have helped the first officer
39:38overcome his reluctance to correct the captain's mistake.
39:42Without question, if the captain wasn't going to respond
39:45by going around, which is what he should have done instantly
39:48and hearing whoop, whoop, pull up,
39:50the co-pilot should have said,
39:52I've got it and done the same thing.
39:58Digging further into the airline's operations,
40:01investigators discover another factor
40:04that could help explain the disastrous landing.
40:07Fuel efficiency incentive?
40:09Garuda recently introduced a policy
40:12that rewards pilots for saving fuel.
40:15In this case, it was a bonus
40:18that would be applied if people minimised the fuel that they used.
40:27Aborting a landing and going around burns more fuel.
40:31But the captain denies he was trying to save fuel
40:34at the expense of his passengers' safety.
40:37He did not at any time seek to excuse his actions
40:40by blaming the company's policy.
40:42We learned in the 80s that we had to get inside a pilot's head
40:46and we had to try to figure out what the state of mind was,
40:49whether he survived or not.
40:51In this particular case, the state of mind has to be so bizarre
40:54in terms of the fixation on getting this airplane on the ground
40:57that it's really hard to understand
40:59how any professional airman could get there.
41:02In 2008, Captain Marwoto Komar faced charges
41:06and was found guilty of negligence.
41:09But the conviction was overturned on appeal
41:12when the Indonesian High Court ruled
41:14that prosecutors failed to convincingly prove their case.
41:20The public reaction was one of horror to this crash.
41:26Particularly as the details came out about what the pilot had been doing.
41:30The fact that he had ignored 15 warnings.
41:34He'd ignored two pleas to go around by the co-pilot.
41:38He was approximately 80 knots too fast on touchdown.
41:43These elements just really portrayed this as a cowboy operation.
41:50In their final report, investigators urge the airline
41:54to scrap the fuel incentive policy.
41:57It's just not a good idea to introduce a scheme
42:02that may compromise safety in order to save costs.
42:06The report also calls for improved pilot training.
42:10We can't change their behaviour, it's already happened.
42:13What we can do is to try to change those conditions
42:17that influence their behaviour
42:19so that we can try to prevent this from happening again.
42:24In the aftermath of the Garuda 200 disaster,
42:28the airline overhauled its training and safety protocols.
42:32The European ban on Garuda was lifted two years after the crash,
42:37and today it is a safer airline than it has ever been.
42:42The impact this crash had on Garuda was a watershed.
42:46They completely went through the operations department,
42:49the flight department.
42:51They've changed everything about the airline.
42:53It went from a pariah in the industry
42:56to a well-respected airline today.
43:01But for the survivors of Garuda Airways Flight 200,
43:05difficult memories remain.
43:07It took me three days before it caught up with me.
43:10The adrenaline and everything in your body,
43:12everything was racing.
43:14And then you get back home and it does settle sort of thing
43:17and it just broke down in a heap.
43:21In recognition of his heroism,
43:23Quinlan is honoured with one of Australia's highest awards,
43:26the Bravery Medal.
43:28I was blessed that I can still walk, I can help people,
43:32and I just tried to help people the best that I could.
43:35You always want to do more, though.
43:37That's the thing.
43:41A lot of people lost their lives that day
43:43and some amazing, remarkable people.
43:46They'll never be forgotten,
43:48but I hope never to see anything like that again, you know.