Original subtitles

NARRATOR: Dramatic video captures a scene of chaos.

GEOFFREY THOMAS: You've got this trail of people

coming away from the airplane.

It was raw, unedited.

NARRATOR: A crash survivor records

the desperate escape from the wreckage of Garuda flight 200.

Huge explosions going off, big plumes of black smoke.

NARRATOR: What sent the Indonesian airliner

careening off the runway?

ALAN STRAY: We don't deal in speculation.

We want facts.

There was intense pressure to deliver.

NARRATOR: Investigators must accept a shocking explanation

for the crash.

It's very hard to understand.

Go around, captain, go around.

I never heard anything like this.

FLIGHT ATTENDANT (ON INTERCOM): Ladies and gentlemen,

we are starting our approach.

PILOT: We lost both engines.

PILOT: Mayday! Mayday!

WOMAN: Brace for impact!

MAN: I think I lost one.

MAN: Investigation started in traffic.

MAN: He's gonna crash!

NARRATOR: It's early morning on the Indonesian island of Java.

Garuda 200, cleared for descent, runway zero niner.

Surface wind is calm.

Visibility is eight kilometers.

NARRATOR: A Boeing 737 flies high overhead.

Copy that.

Runway zero niner.

Winds calm, visibility eight kilometers, 27,000 feet.

27,000.

NARRATOR: The crew of Garuda flight 200

is getting ready to land.

All right, you can go ahead and proceed

with the landing checklist.

COPILOT: Landing lights.

PILOT: On.

Approach frequencies.

Check.

Indonesia is made up of 18,300 islands,

so air travel is incredibly important.

Garuda is critical to the aviation infrastructure.

Fasten seat belt light is on.

NARRATOR: There are 133 passengers in the cabin.

They're nearing the end of a short flight

from the Indonesian capital of Jakarta,

265 miles Southeast of the city of Yogyakarta.

Most of the passengers are Indonesian,

but there's also a group of Australian journalists.

They're covering a state visit by Australia's

foreign minister who's traveling on another plane.

Relationship between Australia and Indonesia

are often strained.

So whenever a minister or a head of state

visits that country, there's a heightened

interest from the media.

And so we had a large media contingent following.

NARRATOR: Kyle Quinlan is also headed to Yogyakarta.

He's an Air Force security officer,

part of the foreign minister's advanced security team.

I was working for 34 VRP Squadron.

They're the guys who look after the security

for Prime Minister, heads of government,

and stuff like that.

We had to travel internally on civilian aircraft.

NARRATOR: The plane is about 15 minutes from touchdown.

Speed is 320 knots.

OK, when we're cleared, we approach runway nine,

course 088.

NARRATOR: Captain Mohammed Marwoto Komar has

been with Garuda for 21 years.

Approach flaps 40.

Auto brake two.

With air speed approximately 141 knots,

on landing, parking stand to the left.

NARRATOR: As they near the airport,

he briefs first officer Gagam Rohmana

on the first steps needed to get their plane on the ground.

Understood?

Approach briefing complete.

This was a typical day out for these pilots.

Captain was very experienced.

The copilot, a little bit less experienced but certainly just

another day at the office.

A short flight, easy.

Enough slacking.

It's time to get back at it.

Yes, sir.

No life like it.

NARRATOR: For Quinlan, the flight's been a welcome break

from a hectic schedule.

We just come off a 16 hour shift the night before.

We had probably about three hours sleep,

and so it was kick back and just relax and just enjoy

this time before we get on the ground

and before we have to work.

NARRATOR: The plane is less than 15

miles from the airport.

Whoa, strong wind.

NARRATOR: They hit some slight turbulence.

What will challenge you in tropical latitudes

close to the equator is the fact

that the weather there has a greater exchange of heat.

And therefore, you're going to get more wild winds.

And you've got to be on your toes as a pilot.

Garuda 200, you're cleared to approach runway zero niner.

Let me know when you have the runway in sight.

Copy that.

NARRATOR: The bumpy ride doesn't

alarm the experienced captain.

Flaps one.

NARRATOR: He continues with a landing approach.

Flaps one.

NARRATOR: And calls for the flaps to be extended.

Flaps increase the wing surface area

adding the crucial extra lift needed at slower speeds.

Gear down.

Gear down.

NARRATOR: They're now less than 3,000 feet above the runway.

Flaps 15.

JOHN NANCE: You're in this position

of taking this big bird and putting it

into a slow enough air speed with enough configuration

on flaps and landing gear and so on that you're

a little bit vulnerable.

NARRATOR: As the plane descends,

Quinlan begins to feel uneasy.

His Air Force training tells him something's not right.

When you travel on aircraft so frequent,

you become aware of your surroundings.

And, for me, it was when we were standing and looking out

the window and thinking, we're not

supposed to be at this height for how fast we were going.

Something's off, huh?

Clear to land two miles out.

NARRATOR: Quinlan can't shake the feeling

the plane's dropping too fast.

When I realized something really bad

was going to happen, I turned to my boss and I said,

we're going in.

OK then.

KYLE QUINLAN: What can you do?

You're stuck here.

There's nothing that you can do except for tighten up the seat

belt and just hang on and just ride this out,

and hopefully, we make it.

AI: Pull up.

Whoa! Go around, captain!

Go around!

AI: Pull up.

We landed, and we bounced.

NARRATOR: It's chaos as the plane bounces a second time.

KYLE QUINLAN: And I just remember thinking, just hang

on, hang on, bud, hang on.

NARRATOR: Then a third impact and the plane isn't stopping.

We're scraping on the belly.

I can hear the wings, the engines, everything.

Then probably the biggest impact

I've ever had on my life was when we hit that embankment.

NARRATOR: Emergency crews race towards the crash site,

but the 737 has careened off the runway

into a swampy rice field.

Getting vehicles to the site won't be easy.

When you've got a crash that occurs

in the middle of an airport where there's plenty

of access, it's one thing.

But when it's out off the airport site,

in this particular case in a rice

paddy, very limited access, it gets almost

exponentially more

difficult.

NARRATOR: Many passengers are badly injured,

and the fire is spreading fast.

Kyle Quinlan realizes there's no time to wait for rescue.

KYLE QUINLAN: Once we pulled up, I could still operate.

And to see so many people who were busted up

and couldn't do anything--

I needed to do something and to help these people out.

NARRATOR: Inside the burning fuselage of Garuda flight 200,

Kyle Quinlan struggles to get out.

Fire is blocking the nearest exits.

KYLE QUINLAN: The whole plan is--

there's just the glow and the heat

coming from the right side of the aircraft.

NARRATOR: If the fuel tanks ignite,

the plane could explode.

But firefighters can't reach the crash.

Any time you've got the possibility of fuel,

you need fire suppression right there

right now because you've got massive flames

at 1,800 degrees.

You've got a lethal situation.

Give me a hand with this.

NARRATOR: Quinlan still can't get out.

KYLE QUINLAN: Turn to my left, jump across,

grab the emergency exit with another Indonesian guy

and crack the emergency exit.

NARRATOR: Passengers scramble out of the door.

KYLE QUINLAN: People are climbing over each other,

and it was a pretty wild scene.

Sir, I've got to get you out of here now.

NARRATOR: Quinlan's Sergeant Michael

Hatton is too badly hurt to get off the plane without help.

KYLE QUINLAN: He was unconscious and falling

in and out of consciousness.

So I carried him out, jumped off the left wing

tip into a rice paddy.

And then sunk up to knee deep in water.

About 100 meters away from the aircraft there's a hut.

I just grabbed my boss and carried him there.

I'm all right.

I'm all right.

I just can't move my arm.

You'll be all right here.

I can see his injuries.

They're not life threatening.

Said look, you'll be all right here.

I'm coming back for you.

You be all right.

I'm coming back.

Off I went and went back to the plane.

NARRATOR: Freelance cameraman Wayan Suricata also

makes his way off the plane.

He soon begins capturing dramatic images

of the aftermath.

GEOFFREY THOMAS: We've got the cameraman gasping for breath.

We've got him staggering around away from the aeroplane

filming as he went.

And you've got this trail of people coming

away from the aeroplane.

It was raw, unedited.

And it was a real sense of being there.

KYLE QUINLAN: The fire and the intensity, it was a massive.

It was like this thing was huge explosions going off,

big plumes of black smoke.

Just how the aircraft was burning,

it was just phenomenal.

I've never seen anything like it.

NARRATOR: Back on board the plane,

Quinlan helps more passengers escape a cabin that's

fast becoming an inferno.

KYLE QUINLAN: A lot of people were not in a condition

to be able to do anything.

So I'm in a condition where I can assist,

I'm going to assist.

I'm going to do the best I can and help.

GEOFFREY THOMAS: The scene was one of chaos.

On one hand, you've got lots of officials

not knowing what to do.

On the other side you've got passengers

almost looking after themselves and rescuing each other coming

away from the wreck.

You've got emergency services who

can't get to the aeroplane because of the terrain,

because of the ditches and the rice paddies.

It really was chaotic.

NARRATOR: Of the 140 passengers and crew on board,

21 people have been killed.

GEOFFREY THOMAS: Clearly, you knew that people were

not going to survive this.

It's almost a miracle that so many did survive.

NARRATOR: Suricata keeps rolling as crash survivors,

including Kyle Quinlan and Michael Hatton,

arrive at a nearby hospital.

Australian Air Force, Air Force.

There was the stretchers and everyone over the floor,

you know?

And it was just a big shock to me, just so many people.

NARRATOR: Within hours, Suricata's dramatic footage

is broadcast around the world.

The public response to that footage

was overwhelming, millions and millions of hits on YouTube.

Television stations around the globe picked it up,

and it was repeated continuously for four days

after the crash.

NARRATOR: At the crash site, investigators from Indonesia's

National Transportation Safety Committee, or NTSC,

faced the enormous task of piecing

together what went wrong.

Aircraft debris is spread all along the plane's

deadly trajectory from the runway

to where it came to rest in the rice field.

JOHN NANCE: An airplane is basically

an aluminum egg shell.

It is incredibly strong when is used the way

it's designed to be used.

But if you skidded off a runway at high speed,

it's not going to stay together.

NARRATOR: Alan Stray of the Australian Transport Safety

Bureau joins the investigation.

What do you got so far?

We have to establish where did it touch down?

Were there any runway marks?

Did it bounce?

Did it skid?

What are the distinguishing features on the runway that

may help us build a picture of what was happening

at the time of the accident.

Let's get the full team out to runway nine.

NARRATOR: Stray knows that the relatives of the dead

are already demanding answers.

GEOFFREY THOMAS: Because there were so

many international people on board

this aircraft, some of whom had died,

there was intense pressure to deliver.

NARRATOR: Investigators search for clues

to explain why Garuda flight 200 bounced off the runway

and crashed.

It looks like they hit pretty hard.

NARRATOR: They discovered gouges and shattered pieces

of landing gear on the runway, clear signs

that the plane slammed down with unusual force.

The nose wheel digging in and fracturing

was indicative of a very hard G-Force on that impact.

NARRATOR: It's also clear the plane

hit the runway more than once.

More skid marks here.

The idea of walking the site is to establish

a sequence of the events.

First impact here.

Being very careful not to disturb

any perishable evidence.

So 1, 2, 3, then off the end of the runway.

There was a lot of questioning and trying to establish

why did the aircraft bounce?

Hang on a minute.

NARRATOR: The location of the first skid mark

gives investigators a crucial lead.

ALAN STRAY: How far are we from the threshold of the runway?

860 meters.

Yikes, that's more than a third of the runway.

It landed long.

It didn't touch down till a long way into the runway.

The distance of the touchdown from the threshold

raised serious questions in the minds of the investigators.

So it comes in long.

He hits hard, and bounce.

Let's gather up as much weather data as we can.

We're very keen to establish was there

a weather situation, a wind or a downdraft,

a strong tail wind.

NARRATOR: Stray suspects wind shear

might explain what he sees.

ALAN STRAY: Like this and like this.

NARRATOR: Wind shear can produce

violent updrafts and downdrafts that

are impossible to fly through.

Close to the ground, it can be deadly.

JOHN NANCE: Especially in the age of climate change,

we've got more and more violent winds, gust fronts,

downdrafts, things of this nature,

and sometimes, microbursts.

NARRATOR: Investigators check with tower controllers

to find out what kind of weather

the pilots were facing as they descended toward the airport.

Here, take a look.

Surface winds were completely calm.

NARRATOR: The weather data shows there were strong winds

at high altitudes.

But the winds near the runway were calm.

There's no sign of the kind of downdrafts that could

force a plane to the ground.

That wind tapered right off, and there was ample time

for the crew to establish the aircraft

in a stabilized approach from 1,000 feet.

NARRATOR: Indonesian police launch

a criminal investigation into the accident.

They bring the captain in for questioning.

For crash investigators, the move

has unfortunate consequences.

I really have nothing more to say.

I'm sorry.

BRENT HAYWARD: In cases where the investigation becomes

criminalized, and particularly when

that happens early on, if we have police

involved or lawyers involved--

We did everything by the book.

BRENT HAYWARD: --that can intimidate people.

And it can lead to them not cooperating effectively

with investigators.

NARRATOR: With the flight crew under criminal suspicion

and reluctant to talk, investigators

must look for other leads.

Downloading the plane's black boxes, or flight recorders,

is now a top priority.

Investigators quickly recover them from the wreckage

and send them for analysis.

All right, let's get these to the lab.

Now, the flight recorders are vitally important.

It's important to get as much information

from them, early information, so

that it may direct the thrust of the investigation.

Without that data, we're screwed.

NARRATOR: Meanwhile, investigators

focus their attention on the crash site.

Every detail is a possible clue.

What I want to know is why they didn't stop

at the end of this runway.

The investigation was initially concerned

about the touchdown point and the remaining

distance on the runway.

Is that the runway map?

NARRATOR: They wonder if, after coming in long,

the plane simply didn't have enough runway

left to stop safely.

JOHN NANCE: Even with a two or three mile runway,

you've got a finite patch of concrete

on which to land an airplane.

They touched down here, 860 meters from the threshold.

Now, that gives him just over 1,300 meters to stop.

NARRATOR: The runway in Yogyakarta

is shorter than the runways at many

other international airports.

But even though the pilots touched down late,

Stray calculates they still had enough room

to stop their plane.

He had more than enough runway.

The length of the runway was completely adequate

for a Boeing 737 landing.

NARRATOR: Investigators need to dig deeper.

We need to know why this plane didn't slow down

once it was on the ground.

I want to take a close look at everything.

NARRATOR: They begin a painstaking analysis

of the major mechanical systems on the 737,

especially those designed to help the plane slow down

and stop on landing, brakes, spoilers,

and thrust reversers.

ALAN STRAY: Was there a mechanical failure?

Looking at the performance of the aircraft,

was it physically possible for the aircraft to stop?

NARRATOR: The careful analysis of the plane's

mechanical systems provides a potential breakthrough.

I think we got something here.

NARRATOR: A review of the maintenance

log for Garuda flight 200 turns up an intriguing lead.

ALAN STRAY: There had been a write up on a couple

of occasions of thrust reversal failure

on one thrust reverser.

NARRATOR: The thrust reversers redirect

the jet's engine exhaust forward to help the plane

slow down on the runway.

JOHN NANCE: You've got to remember,

it's not just a matter of kissing

the wheels onto the ground.

It's a matter of dissipating a tremendous amount

of energy, a tremendous amount of kinetic energy.

How do you do that?

Well, you do it with the friction

between the tires and the runway,

hopefully, using antiskid.

You do it with reverse thrust.

AI: Pull up.

We're not stopping!

No thrust reverser.

NARRATOR: Investigators wonder if a malfunctioning thrust

reverser explains why the crew couldn't stop

before they ran out of runway.

Full brakes!

But at the end of the day, you still have

to dissipate all that energy.

And if you don't have enough room to do it,

you're off the end.

NARRATOR: But it's another dead end.

According to the maintenance records,

the faulty thrust reverser was repaired

before flight 200 took off.

Looks like they fixed it.

That had been rectified prior to this flight

departing from Jakarta.

And so there was no paperwork evidence of a failure.

NARRATOR: Investigators are going to need another lead.

NARRATOR:

We don't deal in speculation.

We want facts.

NARRATOR: The facts so far are limited.

The 737 careened into a rice field

after slamming to the ground almost a third

of the way down the runway.

The question is, why?

Was the plane configured properly?

Perhaps there was something wrong with the wing flaps

pilots rely on for landing.

The flap system on a modern jetliner like a 737

create greater lift, and that means

that we can approach an airport or we

can take off from an airport with a much

lower and safer airspeed.

NARRATOR: The team scrutinizes the mechanical rods or screw

jacks that move the flaps.

ALAN STRAY: We needed to look at the flap setting.

What flap setting can we establish from the wreckage?

We measured the screw jack extension to establish

what the flap setting was.

NARRATOR: What they find is astonishing.

It doesn't look like the flaps are all the way out.

NARRATOR: The screw jacks show a flap

setting of just five degrees, not nearly

enough for a safe landing.

ALAN STRAY: We just could not believe

that the aircraft would have landed with only five degrees.

NARRATOR: To provide enough lift on landing,

the flaps of a 737 are usually extended step

by step from zero all the way to 40 degrees

as the plane slows and descends towards the runway.

It's hard to overstate the value of the flap systems

on a modern jetliner.

NARRATOR: Investigators aren't sure how the flaps

ended up at only five degrees.

The flap mechanism was damaged in the crash

and may have moved on impact.

To be certain of how the flaps were set,

they need to know what's on the flight recorders.

We need that data from the black boxes.

NARRATOR: Some of that data is proving elusive.

Australian technicians have been unable to download

the cockpit voice recording.

It's a huge blow.

BRENT HAYWARD: If you don't have access to the CVR,

for whatever reason, then it's very difficult to understand

what went on in the cockpit.

NARRATOR: Desperate to hear what's on the device,

investigators send it to the US manufacturer

hoping experts there can recover the recording.

ALAN STRAY: So steps were taken to hand carry

the recorder to the factory so that the data

could be downloaded.

NARRATOR: Crash investigators are having

better luck with the second black box,

the flight data recorder.

They've managed to download all of its stored information.

ALAN STRAY: We were able to get information

about the flaps settings, the speed on the approach,

the thrust reverser deployment, the dynamics of the approach

and landing itself.

NARRATOR: The data reveals the 737

was coming in for its landing blazingly fast.

AI: Pull up. - Too low.

Terrain.

NARRATOR: Flight 200 hit the ground

at over 250 miles an hour--

--more than 100 miles an hour faster than normal.

We're not stopping!

JOHN NANCE: This is a ridiculous amount

of speed to approach an airport with the intent of landing.

NARRATOR: The plane's speed at impact

is so fast it bounces twice before skidding

into the rice field.

ALAN STRAY: The speed of the aircraft on short final

and on touchdown is so excessive there was

no way it was going to stop.

NARRATOR: But why did the pilots

touch down on the runway at such

a catastrophically high speed?

Pull up the data for the flaps.

Would you, please?

There, the flaps were set for five degrees.

Never more than five degrees.

NARRATOR: The data confirms what the screw jack

suggested to investigators.

The flaps on flight 200's wings were

in a bizarre position, one that is never used during landing.

It's not operational procedure to land with flaps

five unless there is a jammed flap

and it cannot be extended.

NARRATOR: Investigators are left with an alarming

possibility, that the plane crashed because the pilots

touched down without performing one of the most critical

steps needed for any landing.

To hear an airplane that has been in an accident

because of overrunning the runway

had a flap setting of only five in a 737 is very disturbing.

NARRATOR: Why the crew failed to set their flaps

properly remains a troubling question.

Meanwhile, media reports erode public confidence

in Garuda Indonesia airways.

The accident affected, negatively,

Garuda's reputation, but they had had

other problems in the past.

NARRATOR: In 2002, Garuda flight 421

was forced to ditch in a small river

after both engines flamed out.

And in 1997, Garuda flight 152 slammed into a ravine killing

all 234 people on board.

Garuda's record at that stage was just a series of accidents

and incidents with large numbers

of people losing their lives.

NARRATOR: In the wake of this latest disaster,

Garuda is banned from landing at any airport

in the European Union.

The fate of Indonesia's national airline

could be at stake if investigators

can't figure out what went wrong on board Garuda

flight 200.

Finally.

NARRATOR: After a painstaking data recovery process,

investigators can finally listen

to the cockpit voice recording from Garuda flight 200.

ALAN STRAY: Fortunately, the recorder specialists

at the laboratories are a tenacious breed,

and they do not give up easily.

NARRATOR: But while the sounds captured

in the cockpit shed light on the decisions and actions

of the flight crew?

OK, let's hear it.

PILOT (ON RECORDING): When we're cleared, we approach

runway nine, course 088.

NARRATOR: Investigators listen as the crew discusses

their plans for landing.

BRENT HAYWARD: What you're doing

is listening for the atmosphere and the tone, the ambience,

if you like, in the cockpit.

Approach flaps 40, auto brake two,

with air speed approximately 141 knots.

On landing, park in the stand to the left.

Now, they know they need 40 to land,

but they only get five.

What's going on?

Approach briefing complete.

NARRATOR: At first, there's no sign the crew is worried.

PILOT (ON RECORDING):

The captain certainly doesn't sound stressed.

NARRATOR: Then, the first hint that something is going wrong.

Looks like we're not going to hit the glide slope.

NARRATOR: The plane is too high for this distance

from the airport.

Better get down a little faster.

NARRATOR: To land smoothly, planes

need to lose enough speed and altitude

to descend gradually and meet the runway at a shallow angle.

Flight 200 is much too high.

OK, he's a bit behind, but it shouldn't be a problem yet.

NARRATOR: Stray compares the descent of flight 200

with the flight path they should have been flying.

It is not unusual to be a little behind

in terms of slowing down and especially

in terms of descending.

And sometimes, you find yourself high and fast,

and you've got to make a decision.

He definitely has some work to do

if he hopes to get on track.

Check speed, flaps 15.

Flaps five.

Captain is calling for flaps 15.

Why is he saying flaps five?

Flaps 15.

NARRATOR: Something is very wrong in this cockpit.

Check speed, flaps 15.

NARRATOR: The captain repeatedly

tells the first officer to increase

the flaps to 15 degrees.

But the first officer never moves them past five degrees.

Flaps 15.

It's like they're not even in the same cockpit.

NARRATOR: Landing demands precise crew coordination.

But as they speed towards the runway,

the captain and his first officer

seem to be ignoring each other.

There's a lot of evidence that this crew

was not thinking it through.

They weren't situationally aware.

They weren't communicating.

OK, first things first.

Why did the first officer ignore the captain

and leave the plane at flaps five?

JOHN NANCE: It's very perplexing.

If you've got professional pilots, we can make mistakes.

But usually, that's why we've got two people up there so

one catches the other.

AI: Pull up!

NARRATOR: Investigators suspect the high speed at landing

explains the first officer's decision not

to increase the flap setting.

Way too fast for flaps 15.

NARRATOR: Flaps can be damaged by excessive drag.

And when the captain calls for flaps 15,

the plane is speeding at over 250 miles an hour,

much too fast to safely extend the flaps any further.

Flaps 15.

NARRATOR: The plane is moving so quickly that wind drag

could tear the flaps right off the wings

if the flaps are extended past five degrees.

I can very well understand why the first officer did not

comply on going to flaps 15.

They're grossly over speeding flaps five.

The first officer was exactly right in not

putting them down.

All right, they were moving too fast to deploy the flaps.

But why didn't the first officer say something,

tell the captain to slow down?

One of the issues was that he didn't communicate

his reasoning for not responding

to those commands for flap 15.

He didn't communicate that to the captain.

When you take a pristine Monday morning quarterback,

look at this, regardless of airline,

regardless of culture, it's very clear

that the copilot should have said, captain,

I got the airplane.

But what it tells me here is that this co-pilot

did not feel that he could speak up one way or another.

NARRATOR: Even more bizarre, why didn't the captain react

to the loud alarm sounding in the cockpit

just moments before the first impact?

- Go around, captain!

Go around!

AI: Pull up.

Landing checklist completed, right?

AI: Pull up.

Too low. Terrain.

Pull up.

It's a tough one to ignore.

There's nothing subtle about it.

NARRATOR: The ground proximity warning

is a clear signal to a pilot that he's

flying dangerously low.

AI: Airspeed low.

There were 15 ground proximity alerts

and warnings during that final stage of the approach.

When a crew member hears that, there

should be instant action.

AI: Pull up.

NARRATOR: Instead of aborting the landing,

the captain does something that baffles investigators.

Go round, captain!

Go around!

Landing checklist completed, right?

NARRATOR: He asks the first officer if the landing

checklist is complete.

Landing checklist?

I never heard anything like this.

AI: Pull up.

When the copilot called for the captain to go around

and the captain responded landing checklist complete,

it was just something that we could not understand.

I was appalled.

This was industry worst practice

for crew resource management, a pilot ignoring 15 warnings?

Ignoring two pleas by a copilot to go around,

and landing 79 knots too fast?

This was atrocious.

NARRATOR: For investigators, the question

remains, why did the crew continue

with the landing that was clearly heading for disaster?

Personnel files reveal both Garuda pilots are

fully licensed and certified.

The captain, in particular, has many years of experience.

But his dangerously fast landing attempt

and the poor communication in the cockpit

lead investigators to question the quality

of the crew's training.

There was a much deeper look at what training

had been provided to the crew.

Weak situational awareness and coordination,

poor communication, unstabilized approaches.

NARRATOR: A review of training records for the entire airline

uncovers a disturbing detail.

This is not the first Garuda crew to have problems

with a routine landing.

We noted that in 2001 an analysis had been conducted,

and there was a number of instances

of unstablized approaches or fast approaches by crews.

NARRATOR: The finding shines new light on what

happened in Yogyakarta.

Investigators may finally be zeroing in on the cause

of the Garuda 200 disaster.

Play that last bit again for me.

Would you, please?

NARRATOR: Investigators believe Garuda's

poor training record helps explain the deadly landing

in Yogyakarta.

AI: Pull up.

NARRATOR: High-quality training for pilots

is absolutely critical, especially

when they face a crisis.

AI: Pull up.

NARRATOR: It's one of the few things that

can help a pilot avoid a strange psychological

phenomenon known as fixation.

Fixation is when we are focused on completing a task

to the exclusion of other things

that may be going on around us.

JOHN NANCE: When you see people as egregiously ignoring

all the warnings and the systems

and the bells and the air speed and everything else here,

you've got people who are fixated.

AI: Pull up.

Nothing was getting through to this guy.

NARRATOR: Investigators theorize that the captain was

so fixated on descending to the proper altitude

that he didn't notice his speed.

And even when the alarm sounded,

he failed to realize that his plane was in grave danger.

JOHN NANCE: It's hard to imagine

how somebody could get to that point,

but we have a lot of flaws.

And part of the flaw in the case of a pilot fixating

on a runway is that he or she can blank out

the rest of the advice, the ground proximity warning

system, everything.

NARRATOR: Training helps combat fixation

by reinforcing standard procedures designed to ensure

pilots can break the spell and take

in the information they need.

AI: Pull up.

Go round, captain! Go round!

AI: Pull up.

Go around!

AI: Pull up.

Landing checklist completed, right?

NARRATOR: Better training might also

have helped the first officer overcome

his reluctance to correct the captain's mistake.

JOHN NANCE: Without question, if the captain wasn't going

to respond by going around, which is what he should have

done instantly on hearing, whoop, whoop, pull up,

the copilot should have said I've got

it and done the same thing.

NARRATOR: Digging further into the airlines operations,

investigators discover another factor that could help explain

the disastrous landing.

Fuel efficiency incentive?

NARRATOR: Garuda recently introduced

a policy that rewards pilots for saving fuel.

BRENT HAYWARD: In this case, it was a bonus

that would be applied if people minimized

the fuel that they used.

NARRATOR: Aborting a landing and going around

burns more fuel.

But the captain denies he was trying

to save fuel at the expense of his passenger's safety.

He did not, at any time, seek to excuse his actions by

blaming the company's policy.

JOHN NANCE: We learned, in the 80s,

that we had to get inside a pilot's head.

We had to try to figure out what the state of mind

was, whether he survived or not.

In this particular case, the state of mind

it has to be so bizarre in terms of the fixation

on getting this airplane on the ground

that it's really hard to understand

how any professional airman could get there.

NARRATOR: In 2008, Captain Marwoto Komar

faced charges and was found guilty of negligence.

But the conviction was overturned on appeal

when the Indonesian high court ruled

that prosecutors failed to convincingly prove their case.

The public reaction was one of horror to this crash--

--particularly as the details came out

about what the pilot had been doing,

the fact that he had ignored 15 warnings.

He'd ignored two pleas to go around by the copilot.

He was approximately 80 knots too fast on touchdown.

These elements just really portrayed

this as a cowboy operation.

NARRATOR: In their final report,

investigators urged the airline to scrap

the fuel incentive policy.

BRENT HAYWARD: It's just not a good idea

to introduce a scheme that may compromise

safety in order to save costs.

NARRATOR: The report also calls for improved pilot training.

BRENT HAYWARD: We can't change their behavior.

It's already happened.

What we can do is to try to change those conditions that

influence their behavior so that we can try to prevent

this from happening again.

NARRATOR: In the aftermath of the Garuda 200 disaster,

the airline overhauled its training and safety protocols.

The European ban on Garuda was lifted

two years after the crash.

And today, it is a safer airline than it has ever been.

The impact this crash had on Garuda was a watershed.

They completely went through the operations department,

the flight department.

That changed everything about the airline.

It went from a pariah in the industry

to a well-respected airline today.

NARRATOR: But for the survivors of Garuda airways flight 200,

difficult memories remain.

It took me three days before it caught up with me.

The adrenaline, everything in your body, everything

was racing.

And then, it would get back up and the dust sort of thing.

And I just broke down in a heap.

NARRATOR: In recognition of his heroism,

Quinlan is honored with one of Australia's highest awards,

the bravery medal.

I was blessed that I can still walk, I can help people.

And I just tried to help people as best I could.

You always want to do more though.

That's the thing.

A lot of people lost their lives that day

and some amazing remarkable people.

They'll never be forgotten, but I hope never to see

anything like that again.