Boeing 737-400 PK-GZC (Garuda Indonesia) — Adisutjipto International Airport, Yogyakarta

The National Transportation Safety Committee recommends that airport operators review the procedures and equipment used by airport Rescue and Fire Fighting Services

Publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and

Ensure that any identified deficiencies are corrected.

Have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and

Exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and

The National Transportation Safety Committee recommends that airport operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.

Review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard;

Review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years, in accordance with ICAO Annex 14 Paragraph 9.1.13 Standard; and

The National Transportation Safety Committee recommends that the Yogyakarta airport operator review the Yogyakarta runway complex to ensure that the runway end safety area (RESA) meets the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators review the AEP to ensure holding facilities for the collecting and care of victims and their families are available; and

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the procedures used by airline maintenance organizations for ensuring that flight recorders meet the relevant manufacturers’ specifications with respect to specific aircraft systems such as EFIS or non-EFIS systems.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators review the results of any actual or exercised emergencies, with the aim of correcting any identified deficiencies; and

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the procedures and equipment used by airport Rescue and Fire Fighting Services to ensure that they : a. meet the minimum requirements specified in the ICAO Annex 14; and...

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators have procedures to provide: a. the passenger lists to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin b. the cargo manifest to the crisis center, rescue and fire fighti...

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review the Yogyakarta runway complex to ensure that the runway end safety areas (RESA) meet the dimension Standards prescribed in the International Civil Aviation Organization (ICAO) Annex 14. If the DGCA is unable to meet the RESA Standard in accordance with ICAO Annex 14, it should file a...

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) review its policy, procedures and implementation of flight operation’s surveillance, to ensure that DGCA achieves and maintains, adequate and appropriate regulatory oversight.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators publish a procedure for the appointment of a suitably qualified person, and appoint such a person, to ensure that the Airport Emergency Plan (AEP) manual is updated and is fit for purpose; and

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators have published procedures for emergency response to an aircraft accident outside the airport perimeter to a minimum of distance of 5 NM in accordance with the Transport Minister Decree 47, also noting the ICAO Annex 14 Standard; and

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators exercise the AEP for response to full-scale emergencies, within and outside the airport perimeter, at intervals not exceeding two years; and

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators train and check their crews, in the simulator, for the vital actions and required responses to GPWS and EGPWS warnings.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators ensure that any identified deficiencies are corrected.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airline operators have published procedures that take into consideration the runway end safety area (RESA) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.

The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that airport operators having water or swampy terrain along the departure and arrival paths are equipped, in accordance with the ICAO Annex 14, Paragraph 9.2.2 Standard, with specialist rescue services and fire fighting equipment appropriate to the hazards and risks.

The National Transportation Safety Committee encourages the use of the Flight Safety Foundation (FSF) Approach-and-landing Accident Reduction (ALAR) and Controlled Flight Into Terrain (CFIT) awareness training material by Indonesian airlines. The NTSC recommends that airline operators include ALAR and CFIT awareness modules in their recurrency training programs, and conduct initial ALAR and CFIT t...

The National Transportation Safety Committee recommends that airline operators ensure that their flight crews are trained and checked, in ‘GPWS specific’ simulator training sessions, for the vital actions and required responses to Ground Proximity Warning System (GPWS) and Enhanced Ground Proximity Warning System (EGPWS) warnings.

The National Transportation Safety Committee recommends that Garuda Indonesia review its fuel conservation incentive program policy to ensure that flight crews are in no doubt about its intent, and that there is no perception that such a policy could compromize the safe operation of aircraft.

ensure the passenger lists to be sent to the crisis center, within 1 hour of an accident, to assist in identification of victims and survivors, and notification to next of kin and the cargo manifest to be sent to the crisis center, rescue and fire fighting services and the National Transportation Safety Committee, within 1 hour, to enable hazard mitigation at the accident site

The National Transportation Safety Committee recommends that airline operators ensure that published procedures take into consideration the runway end safety area (RESA) requirement when calculating performance specifications for operations into airports with runways having a RESA that does not meet the ICAO Annex 14 Standard.

The National Transportation Safety Committee recommends that airline operators review the procedures used by their maintenance organizations for ensuring that flight recorders meet the relevant manufacturers’ specifications with respect to specific aircraft systems such as Electronic Flight Instrument Systems (EFIS) or non-EFIS systems.