Beschrijving:
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.
» Confusion over missing Indonesian airplane (Int. Herald Tribune, January 2, 2007)
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: PK-KKW
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: YU-AOO
| Status: | Accident investigation report completed and information captured |
| Datum: | maandag 1 januari 2007 |
| Tijd: | 14:59 |
| Type: |  Boeing 737-4Q8 |
| Luchtvaartmaatschappij: | AdamAir |
| Registratie: | PK-KKW |
| Constructienummer: | 24070/1665 |
| Bouwjaar: | 1989-01-11 (18 years) |
| Aantal vlieguren: | 45371 |
| Aantal vluchten: | 26725 |
| Motoren: | 2 CFMI CFM56-3C1 |
| Bemanning: | slachtoffers: 6 / inzittenden: 6 |
| Passagiers: | slachtoffers: 96 / inzittenden: 96 |
| Totaal: | slachtoffers: 102 / inzittenden: 102 |
| Schade: | Vernield |
| Gevolgen: | Written off (damaged beyond repair) |
| Plaats: | 85 km (53.1 mijl) W van Pambauang ( Indonesië)
|
| Fase: | Kruisvlucht (ENR) |
| Soort vlucht: | Binnenlandse lijnvlucht |
| Vliegveld van vertrek: | Surabaya-Juanda Airport (SUB/WARR), Indonesië |
| Manado-Sam Ratulangi Airport (MDC/WAMM), Indonesië | |
| Vluchtnummer: | 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:
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:
 |
|
Bronnen:
» SKYbrary » Confusion over missing Indonesian airplane (Int. Herald Tribune, January 2, 2007)
Veiligheidsmaatregelen
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Foto's
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 |
Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Surabaya-Juanda Airport en Manado-Sam Ratulangi Airport bedraagt 1666 km (1041 miles).
Accident location: Exact; as reported in the official accident report.
De afstand tussen Surabaya-Juanda Airport en Manado-Sam Ratulangi Airport bedraagt 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.
languages: 
Indonesië
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Indonesië- 6e zwaarste ongeval (toen het plaatsvond)
- 9e zwaarste ongeval (op dit moment)
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