Incident Overview

Date: Wednesday 16 January 2002
Aircraft Type: Boeing 737-3Q8
Owner/operator: Garuda Indonesia Airways
Registration Number: PK-GWA
Location: 22,5 km NE of Yokyakarta – ÿ Indonesia
Phase of Flight: Approach
Status: Destroyed, written off
Casualties: Fatalities: 1 / Occupants: 60
Component Affected: Aircraft Engine(s)Aircraft Engine(s)
Investigating Agency: NTSCNTSC
Category: Accident
A Boeing 737-300 experienced a catastrophic accident during descent over thunderstorms near Mataram. The flight began with a planned route deviation due to thunderstorms, leading to severe turbulence and hail. After approximately 90 seconds, both engines failed, and the crew attempted to reach a gap between storm cells. The aircraft then descended below an overcast cloud layer, prompting a decision to attempt a ditching into a river. The crew’s actions, including a prolonged wait between restart attempts and a failure to adhere to Boeing 737 Operations Manual procedures, contributed to the accident. Similar incidents involving engine flameouts in heavy precipitation occurred in 1988 and 1989, leading to regulatory changes regarding minimum RPM and restricted autothrust usage.A Boeing 737-300 experienced a catastrophic accident during descent over thunderstorms near Mataram. The flight began with a planned route deviation due to thunderstorms, leading to severe turbulence and hail. After approximately 90 seconds, both engines failed, and the crew attempted to reach a gap between storm cells. The aircraft then descended below an overcast cloud layer, prompting a decision to attempt a ditching into a river. The crew’s actions, including a prolonged wait between restart attempts and a failure to adhere to Boeing 737 Operations Manual procedures, contributed to the accident. Similar incidents involving engine flameouts in heavy precipitation occurred in 1988 and 1989, leading to regulatory changes regarding minimum RPM and restricted autothrust usage.

Description

Flight 421 departed Mataram around 15:00 and climbed to the cruising altitude of FL310. During the initial descent the crew decided to deviate from the planned route because of thunderstorms along their planned route. At 16:19 the flight encountered an area of severe turbulence and thunderstorm activity with extremely heavy precipitation and hail. The crew attempted to fly towards a gap between two storm cells. About 90 seconds after entering the thunderstorm, as the airplane descended through about FL180 at a flight idle power setting, both engines flamed out. The crew carried out three unsuccessful attempts to restart the engines followed by one unsuccessful attempt to start the auxiliary power unit (APU). The flight crew’s reported actions to restart the engines and APU however, were contrary to the procedures contained in the Boeing 737 Operations Manual. For instance, they waited only about 1 minute between each restart attempt instead of three minutes. As the airplane descended below an overcast cloud layer at about 8,000 feet, the crew observed the Bengawan Solo River and decided to attempt to ditch the airplane into the river with flaps and landing gear in a shallow, 1 metre deep part of the river. One stewardess did not survive the crash. Similar occurrences (Boeing 737-300 double engine flameout while descending in heavy precipitation with engines at flight idle) happened May 24, 1988 and July 26, 1988. Following these incidents OMB 88-5 and AD 6-14-88 were issued to require minimum rpm of 45% and to restrict the use of autothrust in moderate/heavy precipitation; engine modification was provided for increased capacity of water ingestion. Probable Cause: “The NTSC determines that the probable causes of the accident were the combination of 1) The aircraft had entered severe hail and rain during weather avoidance which subsequently caused both engines flame out; 2) Two attempts of engine-relight failed because the aircraft was still in the precipitation beyond the engines’ certified capabilities; and 3) During the second attempt relight, the aircraft suffered run-out electrical power.”

Primary Cause

Combination of factors: 1) Severe hail and rain during avoidance, causing engine failure; 2) Failed attempts to restart engines due to precipitation beyond engine capabilities; and 3) Run-out electrical power during the second restart attempt.Combination of factors: 1) Severe hail and rain during avoidance, causing engine failure; 2) Failed attempts to restart engines due to precipitation beyond engine capabilities; and 3) Run-out electrical power during the second restart attempt.

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