Date:	Monday 1 January 2007
Time:	14:59
Type:	Boeing 737-4Q8
Owner/operator:	AdamAir
Registration:	PK-KKW
MSN:	24070/1665
Year of manufacture:	1989
Total airframe hrs:	45371 hours
Cycles:	26725 flights
Engine model:	CFMI CFM56-3C1
Fatalities:	Fatalities: 102 / Occupants: 102
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	85 km W off Pambauang -   Indonesia
Phase:	En route
Nature:	Passenger - Scheduled
Departure airport:	Surabaya-Juanda Airport (SUB/WARR)
Destination airport:	Manado-Sam Ratulangi Airport (MDC/WAMM)
Investigating agency:	NTSC
Confidence Rating:	Accident investigation report completed and information captured

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.

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

photo (c) via Werner Fischdick; Denpasar-Ngurah Rai Bali International Airport (DPS/WADD) [PK]; August 2006

photo (c) Werner Fischdick; Paris-Charles de Gaulle Airport (CDG); 31 May 2003

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