Crash-aerien 01 JAN 2007 d'un Boeing 737-4Q8 PK-KKW

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Statuts:	Accident investigation report completed and information captured
Date:	lundi 1 janvier 2007
Heure:	14:59
Type/Sous-type:	Boeing 737-4Q8
Compagnie:	AdamAir
Immatriculation:	PK-KKW
Numéro de série:	24070/1665
Année de Fabrication:	1989-01-11 (18 years)
Heures de vol:	45371
Cycles:	26725
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

Détails:
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:

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.

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

Sources:

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

Opérations de secours

NTSC issued 27 Safety Recommendations

Issued: 22-AUG-2008	To: Angkasa Pura I	B.2008.1.1
An INCERFA (uncertainty) phase is required to be declared when there is concern about the safety of an aircraft or its occupants when communication is not received, or the aircraft fails to arrive within 30 minutes of a prescribed time. The ALERFA (alert phase) is required to be declared when there is apprehension about the safety of an aircraft and its occupants when communication is not received or the aircraft fails to arrive within 60 minutes of a prescribed time. 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: 22-AUG-2008	To: AdamAir	O.2008.1.1
Ensuring that the airlines maintenance organization has appropriate procedures to ensure the serviceability of the complete IRS system; and
Issued: 22-AUG-2008	To: AdamAir	O.2008.1.2
Ensuring that the airlines maintenance engineers are appropriately trained and qualified to trouble shoot IRS defects, other than simply changing the Inertial Reference Unit (IRU) and associated components, and cleaning connections
Issued: 22-AUG-2008	To: AdamAir	O.2008.1.3
Aircraft upset recovery training; both ground school and simulator; and
Issued: 22-AUG-2008	To: AdamAir	O.2008.1.4
The spatial disorientation and its effects.
Issued: 22-AUG-2008	To: AdamAir	O.2008.1.5
The National Transportation Safety Committee (NTSC) recommends that Adam Air 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.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.1
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: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.1
Note the concerns expressed in paragraph 1.18.3 of the Preliminary Factual Aircraft Accident Report
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.10
DGCA to define radar calibration period
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.11
DGCA to review the use of flight plan track display for controlling.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.12
The ATC controller to reconfirm when the target on the radar screen became as a flight plan track.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.13
The ATC controller to reconfirm the aircraft position during transferring to other sector.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.14
MAATS to review the use of color (green) in the radar display to indicate at their authority (jurisdiction).
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.15
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
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.16
The regulator (DGCA) should review the airline operators training syllabus for cockpit crews, specifically related to Inertial Reference System, navigation system abnormalities.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.17
Ensuring that Indonesian airlines maintenance organizations have appropriate procedures to ensure the serviceability of the complete IRS system.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.18
Ensuring that Indonesian airlines maintenance engineers are appropriately trained and qualified to trouble shoot IRS defects throughout the IRS system, other than simply changing the Inertial Reference Unit (IRU) and associated components, and cleaning connections
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.19
Aircraft upset recovery training; both ground school and simulator; and
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.2
Immediately require an extensive inspection of the Adam Air fleet of aircraft.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.20
The spatial disorientation and its effects.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.3
Thoroughly review the adequacy and the implementation of the Adam Air maintenance program.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.4
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.
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.5
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: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.6
MAATS to have operation procedure which shall be approved by DGCA
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.7
MAATS personnel should be trained in accordance with ICAO standard and radar manufacture procedure which include MAATS procedure
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.8
MAATS to have enough number of ATC personnel to meet the operation requirement (for each sector with one executive and one planner).
Issued: 22-AUG-2008	To: DGCA Indonesia	R.2008.1.9
MAATS to do the recurrent training of ATC personnel in simulator every two up to three months for each ATC personnel (EUROCAT requirement).

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Photos

accident date: 01-01-2007
type: Boeing 737-4Q8
registration: PK-KKW

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

Plan

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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