| Status: | Schlussbericht |
| Datum: | 01 JAN 2007 |
| Zeit: | ca 14:59 |
| Flugzeugtyp: | Boeing 737-4Q8 |
| Fluggesellschaft: | AdamAir |
| Kennzeichen: | PK-KKW |
| Werknummer: | 24070/1665 |
| Baujahr: | 1989-01-11 (17 years 12 months) |
| Betriebsstunden: | 45371 |
| Anzahl Zyklen der Zelle: | 26725 |
| Triebwerk: | 2 CFMI CFM56-3C1 |
| Besatzung: | Todesopfer: 6 / Insassen: 6 |
| Fluggäste: | Todesopfer: 96 / Insassen: 96 |
| Gesamt: | Todesopfer: 102 / Insassen: 102 |
| Sachschaden: | Zerstört |
| Konsequenzen: | Written off (damaged beyond repair) |
| Unfallort: | 85 km (53.1 Meilen) W vom Land entfernt von Pambauang (Indonesien)
 |
| Flugphase: | Während des Fluges (ENR) |
| Betriebsart: | Inländischer planmäßiger Passagierflug |
| Flug von: | Surabaya-Juanda Airport (SUB/WARR), Indonesien |
| Flug nach: | Manado-Sam Ratulangi Airport (MDC/WAMM), Indonesien |
| Flugnummer: | 574 |
Unfallbericht:The Adamair flight went missing during a domestic flight to Manado. Last contact was at 14:07 when the flight was enroute at FL350. Initial reports indicate that the flight changed course twice as a result of severe (130 km/h) crosswind. The airplane crashed into the sea. On January 11 part of a jetliner's tail, food trays and other debris was pulled from the sea. On January 25 a U.S. navy ship detected signals coming from the flight recorder.
The FDR was recovered from a depth of on 2000 m August 27. The CVR was recovered on August 28 from a depth of 1900 m.
Investigators found that, during the flight from Surabaya to Manado, the Inertial Reference System (IRS) malfunctioned. Both pilots became engrossed with trouble shooting the IRS anomalies for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. The pilots selected Attitude in the IRS, which disengaged the autopilot. After the autopilot disengaged and the aircraft rolled right and exceeded 35 degrees right bank, the pilots appeared to have become spatially disoriented. Control was lost and the airplane broke up and crashed into the sea.
CAUSES:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on trouble shooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.
OTHER CAUSAL FACTORS:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.
Informationsquelle:
» Confusion over missing Indonesian airplane (Int. Herald Tribune, January 2, 2007)
Official accident investigation report
Sicherheitsempfehlungen
NTSC issued 9 Safety Recommendations
| Issued: 26-JUL-2007 | To: DGCA Indonesia | PK-KKW (1) |
| Of high immediate importance is the present condition of other Adam Airlines aircraft. If the maintenance condition of PK-KKW is an indication of the condition of the Adam Air fleet, and to prevent adverse risk during Adam Air flight operations, the National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) should:
- Note the concerns expressed in paragraph 1.18.3 of the Preliminary Factual Aircraft Accident Report; and
- Immediately require an extensive inspection of the Adam Air fleet of aircraft.
- Thoroughly review the adequacy and the implementation of the Adam Air maintenance program. |
| Issued: 26-JUL-2007 | To: DGCA Indonesia | PK-KKW (2) |
| In the interest of greater importance of safe flying practices, and in order to prevent adverse risk during line operations, the National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) should immediately require:
- All operators to review the training and operational procedures, to ensure that their pilots are appropriately trained in severe weather recognition and avoidance, and that pilots be required to adhere strictly to the flight procedure of severe weather avoidance whenever severe weather is known or expected; and the pilot should continuously recognize their present position and should report the reason if the pilot has deviated from the assigned track.
- All operators to review their training and procedures to ensure that their pilots are trained to correctly perform the initialization of on-board Flight Management Systems. |
| Issued: 26-JUL-2007 | To: DGCA Indonesia | PK-KKW (3) |
| In the interest of improving safe flying and navigation practices, the National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) should immediately require:
1) MAATS to have operation procedure which shall be approved by DGCA.
2) MAATS personnel should be trained in accordance with ICAO standard and radar manufacture procedure which include MAATS procedure.
3) MAATS to have enough number of ATC personnel to meet the operation requirement (for each sector with one executive and one planner).
4) MAATS to do the recurrent training of ATC personnel in simulator every two up to three months for each ATC personnel (EUROCAT requirement).
5) DGCA to define radar calibration period.
6) DGCA to review the use of flight plan track display for controlling.
7) The ATC controller to reconfirm when the target on the radar screen became as a flight plan track.
8) The ATC controller to reconfirm the aircraft position during transferring to other sector.
9) MAATS to review the use of color (green) in the radar display to indicate as their authority (jurisdiction). |
| Issued: 28-NOV-2007 | To: AdamAir | PK-KKW (4) |
| The National Transportation Safety Committee’s (NTSC) investigation into the Adam Air, Boeing 737-400, PK-KKW, accident that occurred on 1 January 2007 near Makassar Strait, during a scheduled passenger flight from Surabaya to Makassar, is continuing.
a. The regulator (DGCA) should ensure that the airline operator addresses the deep concern about the repetitive problems in the Inertial Reference System and ensure they take their best effort to minimise repetitive problems related to the aircraft navigation system.
b. The regulator (DGCA) should review the airline operator’s training syllabus for cockpit crews, specifically related to Inertial Reference System, navigation system abnormalities. |
| Issued: 12-DEC-2007 | To: DGCA Indonesia | PK-KKW (5) |
| The National Transportation Safety Committee recommends that the Directorate General Civil Aviation (DGCA) ensure that all Indonesian airlines include the following in their syllabus of initial and recurrency training:
a. Aircraft upset recovery training; both ground school and simulator; and
b. The spatial disorientation and its effects. |
| Issued: 12-DEC-2007 | To: AdamAir | PK-KKW (6) |
| The National Transportation Safety Committee recommends that Adam SkyConnection Airline review the pilot training syllabus of initial and recurrency training to include the following:
a. Aircraft upset recovery training; both ground school and simulator; and
b. The spatial disorientation and its effects. |
| Issued: 17-MAR-2008 | To: DGCA Indonesia | PK-KKW (7) |
| The National Transportation Safety Committee (NTSC) recommends that the Ministry of Transportation review the related laws and procedures to ensure appropriate salvage capability is resourced and available without delay following an aviation accident requiring underwater aircraft wreckage recovery. In particular the laws and procedures should ensure the requirements of ICAO Annex 13 Paragraph 5.7 are met with respect to the recovery and read-out of the flight recorders without delay. |
| Issued: 17-MAR-2008 | To: Angkasa Pura I | PK-KKW (8) |
| The National Transportation Safety Committee (NTSC) recommends that Angkasa Pura I review its standard procedures to provide an adequate assurance that alternative methods of positive identification and assessing if an aircraft is in distress, when radar track is lost, are promulgated to controllers. The standard procedures should ensure that the ICAO requirements for the declaration of INCERFA and ALERFA are met. |
| Issued: 17-MAR-2008 | To: AdamAir | PK-KKW (9) |
| The National Transportation Safety Committee (NTSC) recommends that AdamAir should review the effectiveness of its training for cockpit crews, specifically related to crew resource management, safety critical systems, and the appropriate use of standard operating procedures, including the Quick Reference Handbook. |
Show all AD's and Safety Recommendations
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Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Surabaya-Juanda Airport to Manado-Sam Ratulangi Airport as the crow flies is 1666 km (1041 miles).
Indonesien