Accident description
Last updated: 17 April 2014
Status:Final
Date:Monday 1 January 2007
Time:ca 14:59
Type:Boeing 737-4Q8
Operator:AdamAir
Registration: PK-KKW
C/n / msn: 24070/1665
First flight: 1989-01-11 (17 years 12 months)
Total airframe hrs:45371
Cycles:26725
Engines: 2 CFMI CFM56-3C1
Crew:Fatalities: 6 / Occupants: 6
Passengers:Fatalities: 96 / Occupants: 96
Total:Fatalities: 102 / Occupants: 102
Airplane damage: Destroyed
Airplane fate: Written off (damaged beyond repair)
Location:85 km (53.1 mls) W off Pambauang (   Indonesia) show on map
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
Narrative:
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.

Events:

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

Official accident investigation report
investigating agency: KNKT
report status: Final
report number: KNKT/07.01/08.01.36
report released:25-MAR-2008
duration of investigation:449 days (1 year 2.8 months)
download report: Boeing 737–4Q8 PK–KKW Makassar Strait, Sulawesi Republic of Indonesia 1 January 2007 (KNKT/07.01/08.01.36)
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Follow-up / safety actions

NTSC issued 9 Safety Recommendations

Show all AD's and Safety Recommendations

Photos

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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).

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