Crash-aerien 01 JAN 2007 d'un Boeing 737-4Q8 PK-KKW - Pambauang
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Statuts:Accident investigation report completed and information captured
Date:lundi 1 janvier 2007
Type/Sous-type:Silhouette image of generic B734 model; specific model in this crash may look slightly different
Boeing 737-4Q8
Immatriculation: PK-KKW
Numéro de série: 24070/1665
Année de Fabrication: 1989-01-11 (18 years)
Heures de vol:45371
Moteurs: 2 CFMI CFM56-3C1
Equipage:victimes: 6 / à bord: 6
Passagers:victimes: 96 / à bord: 96
Total:victimes: 102 / à bord: 102
Dégats de l'appareil: Détruit
Conséquences: Written off (damaged beyond repair)
Lieu de l'accident:85 km (53.1 milles) W de Pambauang (   Indonésie)
Phase de vol: En vol (ENR)
Nature:Transport de Passagers Nat.
Aéroport de départ:Surabaya-Juanda Airport (SUB/WARR), Indonésie
Aéroport de destination:Manado-Sam Ratulangi Airport (MDC/WAMM), Indonésie
Numéro de vol: 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

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

Opérations de secours

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

Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Surabaya-Juanda Airport et Manado-Sam Ratulangi Airport est de 1666 km (1041 miles).
Accident location: Exact; as reported in the official accident report.

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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