Final report issued on the crash of Adam Air Flight 574

A final report on the crash of an Adam Air Boeing 737-400 (registration number PK-KKW) in January of 2007 has been issued by Indonesia's National Transportation Safety Committee (NTSC), the agency responsible for aircraft accident investigations in that country. The NTSC report concluded that the pilots lost control of the airliner after becoming preoccupied with malfunctioning navigational equipment -- specifically, the aircraft's Inertial Reference System (IRS) . The aircraft plunged into the sea at a high rate of speed. All 102 people on board were killed, including 96 passengers, four cabin crew, and the two pilots.

Adam Air Flight DHI-574 disappeared from radar on New Year's Day, 2007, during the cruise phase of a scheduled domestic flight between Surabaya (SUB), on the island of Java, to Manado (MDC), on Sulawesi island. After an extensive search on land and at sea some debris from the aircraft was found nine days after the accident.

On January 21, 2007, signals from the downed jetliner's flight data recorder were detected by an American ship that had been assisting with the search. The aircraft's Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) finally were retrieved from the seabed in late August of 2007. Much of the NTSC's accident investigation centered on analysis of data from these recorders.

The Synopsis section of the NTSC's final report says the following:

The CVR revealed that both pilots were concerned about navigation problems and subsequently became engrossed with trouble shooting Inertial Reference System (IRS) anomalies for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. This included identification and attempts at corrective actions.

The DFDR analysis showed that the aircraft was in cruise at FL 350 with the autopilot engaged. The autopilot was holding 5 degrees left aileron wheel in order to maintain wings level. Following the crew’s selection of the number-2 (right) IRS Mode Selector Unit to ATT (Attitude) mode, the autopilot disengaged. The control wheel (aileron) then centered and the aircraft began a slow roll to the right. The aural alert, BANK ANGLE, sounded as the aircraft passed 35 degrees right bank.

The DFDR data showed that roll rate was momentarily arrested several times, but there was only one significant attempt to arrest the roll. Positive and sustained roll attitude recovery was not achieved. Even after the aircraft had reached a bank angle of 100 degrees, with the pitch attitude approaching 60 degrees aircraft nose down, the pilot did not roll the aircraft’s wings level before attempting pitch recovery in accordance with standard operating procedures. The aircraft reached 3.5g, as the speed reached Mach 0.926 during sustained nose-up elevator control input while still in a right bank. The recorded airspeed exceeded Vdive (400 kcas), and reached a maximum of approximately 490 kcas just prior to the end of recording.

A thump, thump sound was evident on the CVR about 20 seconds from the end of the recorded data. Flight recorder data indicated that a significant structural failure occurred when the aircraft was at a speed of Mach 0.926 and the flight load suddenly and rapidly reversed from 3.5g to negative 2.8 g. This g force and airspeed are beyond the design limitations of the aircraft. At the time of the thump, thump sound, the aircraft was in a critically uncontrollable state. [NTSC Accident Investigation Report No. KNKT/07.01/08.01.36, Synopsis, pp. 1-2]

The report faulted the pilot in command for failure to manage crew task sharing, and for not following crew resource management practices. The report noted, "There was no evidence that the pilots were appropriately controlling the aircraft, even after the BANK ANGLE alert sounded as the aircraft’s roll exceeded 35 degrees right bank."

This accident resulted from a combination of factors, including the failure of the pilots to adequately monitor the flight instruments, particularly during the final 2 minutes of the flight. Preoccupation with a malfunction of the Inertial Reference System (IRS) diverted both pilots’ attention from the flight instruments and allowed the increasing descent and bank angle to go unnoticed. The pilots did not detect and appropriately arrest the descent soon enough to prevent loss of control. [NTSC Accident Investigation Report No. KNKT/07.01/08.01.36, Synopsis, p. 2]

Among the other factors that contributed to the cause of the accident, the report found that the carrier, privately owned Adam Air, "did not provide their pilots with IRS malfunction corrective action training in the simulator, nor did they provide aircraft upset recovery training in accordance with the Airplane Upset Recovery Training Aid developed by Boeing and Airbus." Adam Air management also was faulted for being unaware of the seriousness of "unresolved and recurring defects" related to the aircraft's Inertial Reference System, referring to the finding that maintenance records and pilots' reports showed that there were 154 such defects reported between October and December of 2006. As well, the report noted several failings by Indonesia's Directorate General of Civil Aviation (DGCA) to properly oversee Adam Air's fleet maintenance practices.

The entire report has been posted to the NTSC website. Here is the link:

NTSC Accident Investigation Report No. KNKT/07.01/08.01.36 - NTSC of Indonesia, March 25, 2008

This is a 98-page 'pdf' file, so it may take awhile to load.

A shorter summary is available as a part of a media release issued by the NTSC, announcing their report (4-page 'pdf' file).

Related: Click here to view all posts about Adam Air Flt 574 on Aircrew Buzz.

Indonesia's Adam Air operations halted

It looks like financial difficulties and safety concerns have led to the demise of Indonesian low-cost carrier Adam Air. Budhi Mulyawan Suyitno, director general for air transportation in Indonesia, has announced that Adam Air's Air Operator Certificate (AOC) has been suspended, and all of the carrier's aircraft have been grounded.

An AFP news article reports:

Suyitno said the decision to remove the beleaguered airline's permission to fly was based on the results of a quarterly safety evaluation, which found it made "violations that could put passengers' safety at risk."

The airline would be grounded until it was evaluated again in another three months, and would have its air operator certificate -- a separate safety certification -- permanently removed if no improvements were found. This would therefore move the company a step closer to permanent closure.

Privately owned Adam Air, which was founded in 2003, has been experiencing financial difficulties for some time. Adam Air defaulted on aircraft leases and insurance payments, resulting in the loss of half its fleet of planes. The carrier's financial woes came to a head last week when a major investor, Bhakti Investama, withdrew as a shareholder.

Bhakti Investama's decision to sell its 50% stake in Adam Air followed the airline's most recent accident, on March 10, 2008. That afternoon a Boeing 737-400 aircraft operated by Adam Air ran off the runway at Hang Nadim Airport in Batam, Indonesia. The accident happened as Flight KI292 landed at Batam after a scheduled flight from Jakarta with more than 170 people on board. Although there were no fatalities, five people injured in the accident were hospitalized.

The March 10 event was the latest of several serious accidents involving aircraft operated by Adam Air. On New Year's Day, 2007, Adam Air Flight 574 disappeared during a domestic flight between Surabaya and Manado. All 96 passengers and six crew members aboard the Boeing 737-400 were presumed to have died.

In February of 2007, Indonesia's Directorate General of Air Communications (DGAC) grounded all seven of Adam Air's B737-300 aircraft. The order followed a 'hard landing' at Surabaya that resulted in cracking and buckling of the aircraft's fuselage.

Here is a list of previous Aircrew Buzz articles about Adam Air:

• What happened to Adam Air flight 574? - Jan. 8, 2007
• Debris from Adam Air jet found - Jan. 11, 2007
• Adam Air flight 574 flight data recorder found? - Jan. 25, 2007
• Adam Air B737-300 fleet grounded - Feb. 22, 2007
• Recorders retrieved from Adam Air Flight 574 crash site - Aug. 28, 2007

Recorders retrieved from Adam Air Flight 574 crash site

Remember Adam Air Flight 574, the Indonesian airliner that disappeared on New Year's Day? The aircraft's flight recorders -- the so-called 'black boxes' -- finally have been recovered from the seabed where the wreckage of the Boeing 737-400 has lain since January. Both the flight data recorder (FDR) and the cockpit voice recorder (CVR) were retrieved from a depth of 1800 meters off the western coast of the Indonesian island of Sulawesi.

An article on Flight Global.com about the recovery of the devices quotes Indonesian National Transportation Safety Commission (NTSC) chairman Tatang Kurniadi who said that the recorders were retrieved by Phoenix International, an American marine services company.

“According to the preliminary information there is only a little bit of physical damage but it is too early to say [if data can be retrieved].”

He adds: “I hope that we will be able to get the data so that we can finish the job [investigating] as soon as possible.”

Kurniadi says the recorders will be sent to the USA for attempted data retrieval by the National Transportation Safety Board.

Adam Air Flight 574 disappeared mysteriously during a domestic flight between Surabaya, Java, and Manado, on Sulawesi island. All 96 passengers and 6 crew members were lost in the accident. Despite a huge search over a wide area, no debris was found until 10 days after the aircraft disappeared. No bodies were ever recovered.

In late January, a US oceanographic vessel reportedly located the area on the seabed where the aircraft's recording devices lay, but retrieval required specialized equipment that was not readily available at that time. Over the ensuing months, the Indonesian government and officials at privately owned Adam Air disagreed over who should bear the cost of the recovery operation. FlightGlobal.com now reports that insurance underwriters are believed to have agreed to pay for the recovery costs.

Let's hope that the CVR and FDR data can be read so that the cause of this terrible accident can be determined, and the mystery solved.

Related: Click here to view all posts on this blog about Adam Air Flt 574.

FAA: Indonesia not in compliance with safety standards

Yesterday the U.S. Federal Aviation Administration (FAA) announced that "Indonesia does not comply with international safety standards set by the International Civil Aviation Organization (ICAO), following a consultation with the Indonesian civil aviation authority on March 6, 2007." This strongly worded statement came in a press release, which is now posted on the FAA website.

Through its International Aviation Safety Assessments (IASA) program, the FAA rates countries -- not individual carriers -- for compliance with international safety standards and practices for aircraft operations and maintenance, as established by the ICAO. The IASA program defines just two categories: Category 1, in compliance; and Category 2, not in compliance. The FAA has lowered Indonesia's rating from Category 1 to Category2.

In applying a Category 2 rating to a country, the FAA states that the country's civil aviation authority (CAA) has one or more of the following deficiencies:

• the country lacks laws or regulations necessary to support the certification and oversight of air carriers in accordance with minimum international standards
• the CAA lacks the technical expertise, resources, and organization to license or oversee air carrier operations
• the CAA does not have adequately trained and qualified technical personnel
• the CAA does not provide adequate inspector guidance to ensure enforcement of, and compliance with, minimum international standards

AND:

• the CAA has insufficient documentation and records of certification and inadequate continuing oversight and surveillance of air carrier operations

In the present case, the FAA says the agency will remain engaged with Indonesia's civil aviation authority "and will periodically review the situation with the intention of encouraging improvements that will qualify Indonesia for a Category 1 rating."

One immediate result of this concern is reflected in the final paragraph of an article published today on the Voice of America website, which says that, "the U.S. embassy in Jakarta on Tuesday warned its citizens not to fly on Indonesian airlines, saying that recent air disasters raise questions about the safety practices of Indonesia air carriers."

Attention has been focused on air safety issues in Indonesia following a series of accidents and safety incidents involving aircraft operated by the country's national flag carrier Garuda, and privately owned Adam Air.

Indonesia wants to ban older airliners

Following a recent string of aviation accidents -- most notably the New Year's Day loss of Adam Air Flight 574, and the more recent damage to another Adam Air plane after a hard landing -- Indonesia is planning to ban local carriers from flying passenger planes that are more than 10 years old. The age limit is intended to improve commercial aviation safety in Indonesia, according to the Indonesian national news agency, Antara.

A Reuters article about this move quotes Indonesia's Transport Minister, Hatta Rajasa, who said, "Our commercial aircraft are 20 years old. We will modernize, rejuvenate our aircraft by enacting an age limit on aircraft of 10 years old." Hatta said that currently the age limit was 35 years or 70,000 landings, Antara reported.

Interestingly, an article published in the International Herald Tribune, and elsewhere, says that the current age limit for planes in Indonesia is 20 years.

It's a little unclear how the new limit on aircraft age would be applied, since Hatta also said that at the time of leasing the plane should be no more than 10 years old, according to Antara. Does that mean that a plane that is, say, 8 years old at the time of leasing will only be allowed to fly for two years? If so, Indonesian carriers will have to start spending a lot more money to acquire much newer planes.

In any case, it's odd that the age of the plane, per se, is being emphasized, rather than the number of cycles (takeoffs and landings) -- usually considered to be a better measure of aircraft 'age.' Perhaps something was 'lost in translation' here between what was first published by Antara and what was published in the English language press?

Perhaps an even more important issue than aircraft age is the quality and frequency of the maintenance performed on airliners. In the end, modernizing and improving maintenance facilities and practices in Indonesia may be a better solution for improving safety than merely modernizing country's commercial airliner fleet.

Adam Air B737-300 fleet grounded

Indonesian carrier Adam Air is in the news again, after all seven of its B737-300 aircraft were grounded by the country's aviation regulator, the Directorate General of Air Communications (DGAC), pending airworthiness inspections. The action came after one of the aircraft was damaged when it made a hard landing in Surabaya yesterday.

'Hard landings' are not uncommon, but this one caused cracking and buckling of the aircraft's fuselage. Flight International published a photo of the damaged aircraft, captured from an Indonesian television broadcast, that shows the aircraft with a buckled mid-fuselage, and its rear section tilted a few degrees lower towards the ground.

An article published in the International Herald Tribune reports that although there were no serious injuries, passengers said the plane came down with such force that baggage compartments burst open, sending luggage flying through the cabin.

A Reuters India report also said that all 148 passengers aboard the aircraft were safe, but that the accident prompted the temporary closure of Juanda Airport in Surabaya, which is Indonesia's second-largest city and the capital of East Java province.

Last week, a press release posted on the Adam Air website announced that carrier was recognized as the Low Cost Carrier Airline of the Year for 2006, at the 3rd Annual Asia, Pacific & Middle East Aviation Outlook Summit. In marked contrast, 2007 has so far been a very bad year for Adam Air, beginning on New Year's Day when one of its B737-400 aircraft vanished during a flight between Surabaya and Manado. Although some debris from the aircraft has been found, and there were reports that the flight data recorder may have been located, there has been no sign of the 96 passengers and 6 crew who were aboard Adam Air flight 574.

Nevertheless, the airline's management has tried to maintain a positive outlook. An article published earlier this month in the International Herald Tribune reported that Adam Air was going forward with plans for expansion. Those plans include acquisition of 10 more B737 aircraft this year, through leasing arrangements. Earlier reports also mentioned possible new routes for the airline. It is still unclear what effect this latest setback will have on those plans.

UPDATE Feb. 26, 2007: Three of Adam Air's grounded 737-300 aircraft have been released to fly again, according to an article from Antara, published on Airport Business. The article reports that "three aircraft met the standard of airworthiness and the three other will also be allowed to resume operation if they are also found to be fit."

Adam Air flight 574 flight data recorder found?

The major news services are reporting today that the flight data recorder from Adam Air Flight 574 may have been located. The aircraft, a Boeing 737-400, disappeared on New Year's Day during a domestic flight in Indonesia. It is believed to have crashed, although only small pieces of wreckage have been found so far. The flight had 102 souls on board, and while no bodies have been found, all are presumed to have perished.

A Reuters article on Airwise.com says that signals believed to be coming from the downed jetliner's flight data recorder have been detected by an American ship that has been assisting with the search. The USNS Mary Sears, an oceanographic survey ship with specialized equipment, found heavy debris scattered over a wide area and was analyzing the data.

"During the search of the projected crash site of Adam Air Flight 574, the Mary Sears, using a Towed Pinger Locator, detected pingers on the same frequency of the black box associated with the missing airplane," the US embassy said in a statement.

An Associated Press article, published on the CBS News website and elsewhere, elaborates:

The hull of the aircraft has not yet been recovered, but the statement said the Mary Sears "detected heavy debris scattered over a wide area" close to where the signals were coming from.

Eddy Suyanto, the Indonesian air force commander in charge of the search and rescue mission, said he had not been formally told of the ship's findings.

"One thing is for sure, up until this second, I have not received any report from the (Indonesian) liaison officers who were on board the ship," he said.

The device may indeed have been located, but retrieving it from the depths of the sea may be another thing entirely. According to an an article on the BBC News website:

Officials said the government would now have to decide whether to try and retrieve the boxes from the ocean bed.

"We do not have the technology to retrieve the black boxes," Setio Rahardjo, chairman of the National Commission on Transport Safety told AFP news agency.

"Assuming we have the funds, then we have to ask for a country who has sophisticated technology, such as the US," he added.

I will continue to post key developments in the story of Adam Air flight 574 as they occur.

UPDATE Jan. 26, 2007: The Associated Press is reporting that Indonesia will attempt to retrieve the flight data recorder from Adam Air flight 574 from the sea floor. Since the water at the site where signals from the device were detected is so deep, the operation might turn out to be prohibitively expensive. Nevertheless, Adam Air spokesman Ali Leonardi said, "If the signals really were from the black boxes and the technology is available to retrieve them, we will keep on trying. It does not matter what the cost."

Debris from Adam Air jet found

The BBC is reporting that debris from the Adam Air B737-400 that went missing on New Year's Day has been found by fishermen just off the western coast of Sulawesi island. The BBC article says that a piece of the aircraft's tail was identified as belonging to the missing jet by a serial number.

"This morning I announced that there has been a finding of a part of Adam Air. What was found was the right tail's stabiliser, number 65C25746-76," the head of the search and rescue mission, Eddy Suyanto, told reporters.

Mr Suyanto said the fragment of the plane was found by a fisherman at 0300 local time on Thursday (2000 GMT Wednesday).

The section was found some 300m (985 ft) from the shore, near Parepare, a seaside town north of Makassar, capital of South Sulawesi province, Mr Suyanto said.

Later reports said a life vest and parts of airline seats had also been found.

It is still unclear whether the plane crashed into the sea, or if it exploded in mid-air.

Still no word on what a US Navy oceanographic vessel deployed to the search area may have found.

Technorati Tags: Adam Air, aircraft accidents, airliners, airline news, Indonesia

What happened to Adam Air flight 574?

What an aviation story to begin the new year. On New Year's Day, an aircraft belonging to Indonesian carrier Adam Air disappeared on a domestic flight between Surabaya, on the island of Java, and Manado on Sulawesi island. The plane, a Boeing 737-400, had 102 souls aboard -- 96 passengers and 6 crew.

Not long after the plane went missing, there were reports that the wreckage had been spotted, and that there might be some survivors. One of those reports was an Associated Press story, appearing on the CNN website and elsewhere, that said:

Rescuers found the smoldering wreckage Tuesday of an Indonesian jetliner that went missing during a storm. Officials said 90 people were killed but 12 survived in the country's second disaster in days.

...

The Boeing 737 operated by local carrier Adam Air crashed in a mountainous region of Sulawesi island in the northeast of the sprawling archipelagic nation, said local police Chief Col. Genot Hariyanto.

"The plane is destroyed and many bodies are around there," he said.

Adam Air spokesman Hartonom, who goes by just one name, said 90 people were killed and that there were 12 survivors.

Officials said rescuers were trying to evacuate survivors, but there was no immediate word on their conditions.

News about an aircraft accident is always sad, but hearing that there are some survivors does make the bad news a little easier to take.

But the next day the story about finding the wreckage and some survivors turned out to be false -- direct quotes and all! An article in the International Herald Tribune reported the following:

Officials said they had been misled by incorrect reports from villagers and local officials in the remote area where the wreckage was alleged to have been found. They plan to resume looking for the aircraft on Wednesday.

"We apologize for the news that we released earlier," said an Air Force official, Eddy Suyanto, the Associated Press reported. "It was not true."

I beg your pardon??

Meanwhile, the NTSB issued a press release announcing that they were sending a team to Indonesia to assist with the investigation, and the names of the crew who were aboard the missing plane were posted on Indonesian blogger Ikatan Remaja PLN's Site.

CNN did a story about the renewed search for wreckage or any other sign of the aircraft.

Three teams of searchers -- 750-800 people in all -- began fanning out Wednesday in Sulawesi in central Indonesia, journalist John Aglionby told CNN.

Meanwhile, three navy ships and five air force craft were deployed soon after sunrise over a large section of south and western Sulawesi and nearby waters, Bambang Karnoyudho, the head of the National Search and Rescue Agency, told the Associated Press.

The effort to locate locate the wreckage of the missing passenger jet intensified after reports from aviation and transport officials came out that the crash site -- and survivors -- had been found.

"The search and rescue team is still looking for the location," Transport Minister Hatta Radjasa told El-Shinta radio, according to The Associated Press. He blamed villagers for spreading rumors that the wreckage had been located. "It has not yet been found."

By then, according to Reuters, the relatives of the missing passengers and crew were in an uproar -- rightly so -- and officials of the airline and the Indonesian government began pointing fingers at one another. About the only facts that could be independently verified were that there was bad weather along the route of Flight 574 that day, and that it disappeared about an hour before it was due to land in Manado.

So, did it crash into the sea? Would wreckage be found in a jungle, or on a mountainside? The Indonesian Air Force and Navy searched a wide area over Sulawesi's western coast and the Java Sea, according to an Associated Press article published on January 3 on Airport Business.

On January 4, Reuters reported that aircraft from Singapore were now assisting with the search. (We also learned that day that three of the passengers aboard the missing plane were Americans, a fact confirmed to reporters by the U.S. Embassy in Jakarta.)

Early on, Indonesian officials had said that the pilots of Flight 574 had sent at least one distress signal before the plane disappeared, but on January 5, an Associated Press article reported:

An Indonesian jetliner that vanished with 102 people aboard did not issue distress signals or report any mechanical problems, a top aviation official said Thursday, contradicting earlier reports.

"Contradicting earlier reports"...? Where have we heard that before?

Iksan Tatang, the director general of air transportation, said the missing plane reported high winds before losing contact with the ground on Monday midway through its flight from Indonesia's main island of Java to Manado on Sulawesi Island.

"The plane did not report any complaints about the navigation, the condition of the plane or other technical problems," he said, adding that two signals from its emergency beacon - which is activated on impact - were picked up by a plane in the vicinity and a satellite.

That appeared to contradict earlier reports from officials that the pilot sent out two distress signals before the plane went down.

On January 5, there was still no sign of the missing plane, but that day stories in the news media revealed that the aircraft had changed course a couple of times before disappearing. An Associated Press article appearing in the Boston Globe and elsewhere said:

The plane left Indonesia's main island of Java for Manado on Sulawesi but altered course and turned westward halfway into the two-hour trip after being warned of rough weather near the city of Makassar, said Eddy Suyanto, head of the search and rescue mission.

But when it ran into winds of more than 80 mph over the Makassar Strait, it changed course again, bringing the plane eastward toward land, then disappeared from the radar, he said.

It is not clear why there have been no transmissions from the plane's emergency locator.

By yesterday, more helicopters and a U.S.Navy ship had joined in the search. Fox News also reported that the NTSB team had arrived in Indonesia from the U.S., as well as representatives from Boeing, the Federal Aviation Administration and General Electric.

This morning, January 8, a Reuters story said that an Indonesian navy ship had detected a large object under the sea off the west coast of Sulawesi. Whether the 'object' will turn out to be a Boeing 737 is anyone's guess. Reuters also said that a U.S. ship with sonar capability and the ability to detect underwater metal, the USNS Mary Sears, is due to arrive tomorrow to join the search.

We can only hope that -- for the sake of the families of the crew and passengers, at least -- the plane, or some concrete sign of it, will be found. For now, after all of the conflicting reports and contradictions, all we can say with certainty is that Adam Air flight 574 vanished on New Year's Day.

Technorati Tags: Adam Air, aircraft accidents, airliners, airline news, Indonesia