ASN Aircraft accident Boeing 737-4Q8 PK-KKW Pambauang
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Status:Accident investigation report completed and information captured
Date:Monday 1 January 2007
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different
Boeing 737-4Q8
Registration: PK-KKW
MSN: 24070/1665
First flight: 1989-01-11 (18 years)
Total airframe hrs:45371
Engines: 2 CFMI CFM56-3C1
Crew:Fatalities: 6 / Occupants: 6
Passengers:Fatalities: 96 / Occupants: 96
Total:Fatalities: 102 / Occupants: 102
Aircraft damage: Destroyed
Aircraft fate: Written off (damaged beyond repair)
Location:85 km (53.1 mls) W off Pambauang (   Indonesia)
Phase: En route (ENR)
Nature:Domestic Scheduled Passenger
Departure airport:Surabaya-Juanda Airport (SUB/WARR), Indonesia
Destination airport:Manado-Sam Ratulangi Airport (MDC/WAMM), Indonesia
Flightnumber: 574
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.

Probable Cause:

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.

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.

Accident investigation:

Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 1 year and 3 months
Accident number: KNKT/07.01/08.01.36
Download report: Final report

Loss of situational awareness

Loss of control

» SKYbrary 
» Confusion over missing Indonesian airplane (Int. Herald Tribune, January 2, 2007)

Follow-up / safety actions

NTSC issued 27 Safety Recommendations

Show all...


photo of Boeing-737-4Q8-PK-KKW
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: PK-KKW
photo of Boeing-737-4Q8-YU-AOO
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: YU-AOO

Aircraft history
date registration operator remarks
11 JAN 1989 G-BNNL Dan-Air Services
07 NOV 1992 G-BNNL British Airways airline merged
19 MAR 1995 G-BNNL GB Airways
06 APR 2001 G-BNNL National Jet Italia leased
26 FEB 2002 N112TR WFBN
04 MAR 2002 EI-CXH Air One leased
20 DEC 2002 YU-AOO JAT leased
13 MAR 2003 N240LF ILFC returned
27 MAR 2003 YU-AOO JAT Airways leased
17 DEC 2005 PK-KKW Adam Air leased

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).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
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