What happened
On 19 October 2015, an ATR 72-600, registration PK-GAF, operated by PT. Garuda Indonesia, was performing a scheduled passenger flight from Kupang to Ende. During the final approach to runway 27 at H. Hasan Aroebo .esman Airport, the aircraft's approach became unstable. The pilot flying increased the rate of descent at approximately 400 feet, causing the airspeed to rise to roughly 140 knots.
The aircraft initially touched down on the touchdown zone with the nose wheel striking the runway first. This contact caused the aircraft to bounce toward the left of the runway centerline. A second bounce occurred, this time on the left shoulder of the runway. During this second impact, the crew applied conflicting control inputs—the pilot in command pitching down while the second in command pitched up—which triggered a "Pitch Disconnect" warning. The crew subsequently initiated a go-around and diverted to Labuan Bajo to ensure safety.
The investigation
The KNKT investigation focused on landing techniques and crew coordination, as the aircraft's airworthiness was not in question. Investigators analyzed Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) data, noting that the approach speed exceeded required limits. The investigation also examined the crew's response to the first bounce and the subsequent management of the aircraft during the second impact.
Furthermore, the inquiry looked into the reporting process. It was discovered that the incident was not immediately reported to the airline's Safety Department, and the delay in reporting led to the CVR data being overwritten by subsequent flight sectors. The investigation also noted that the airline's visual maneuvering chart for the airport lacked specific procedures for avoiding an atoll on the final approach path.
Findings
- The flight crew continued an unstabilized approach characterized by excessive speed, a nose-down attitude, and a slight left bank.
- The crew failed to initiate an immediate go-around following the first touchdown bounce.
- Conflicting pitch inputs from the two pilots during the second bounce caused the pitch control mechanism to uncouple.
- Inadequate Crew Resource Management (CRM) was observed, specifically regarding the lack of coordination during the landing phase and the second pilot's unannounced manual inputs.