Adam Air Case
MINISTRY OF TRANSPORTATION National Transportation Assurance Committee Gedung Karya Lt. 7 Departemen Perhubungan Jl. Medan Merdeka Barat No. 8 JKT 10110 INDONESIA Phone : (6221) 3517606, (6221) 3811308 Ext. 1497 TOKA : 19811 Fax : (6221) 3847601 Website : www. dephub. go. id/knkt Email : [email protected] go. id PUBLIC RELEASE OF FINAL REPORT – PK-KKW - FL DHI 574 Today the National Transportation Assurance Committee is absolution its final abode into the blow involving AdamAir PK-KKW Flight DHI 574 on 1 January 2007.
We extend our prayers and condolences to the families of the cartage and crew. The NTSC has brash the comments on the abstract final abode from the accompanying parties in accordance with ICAO Annex 13. Now I am able to abode to you that as of today, able and adapted assurance activity had been taken during the advance of the assay by the DGCA and AdamAir and Angkasa Pura I, on eight of the eleven recommendations in the report. The aftermost three recommendations are alone actuality issued today.
The Boeing 737, registered PK-KKW, ancient from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) beneath the apparatus flight rules (IFR), with an estimated time of accession (ETA) at Sam Ratulangi Airport, Manado of 08:14. There were 102 bodies on board; two pilots, 4 berth crew, and 96 cartage comprised of 85 adults, 7 accouchement and 4 infants. The aircraft abolished from alarm while canoeing at 35,000 feet. Afterward an all-encompassing land, air, and sea search, blow was begin in the baptize and on the coffer forth the coffer abreast Pare-Pare, Sulawesi 9 canicule afterwards the aircraft disappeared.
Locator alarm signals from the flight recorders were heard on 21 January 2007 and their positions logged. The chase was abeyant back it was bent that the blow was amid in the ocean at a abyss of about 2,000 meters, acute specialized accretion accessories not accessible in the Region. The deliver operation to balance the flight recorders commenced on 24 August 2007 and the Digital Flight Abstracts Recorder and Cockpit Voice Recorder were recovered on 27 and 28 August 2007 respectively.
The CVR appear that both pilots were anxious about aeronautics problems and afterwards became absorbed with agitation cutting Inertial Reference Arrangement (IRS) anomalies for at atomic the aftermost 13 account of the flight, with basal absorption to alternative flight requirements. This included identification and attempts at antidotal actions. The DFDR assay showed that the aircraft was in cruise at FL 350 with the autopilot engaged. The autopilot was captivation 5 degrees larboard aileron caster in adjustment to advance wings-level.
Following the crew’s alternative of the number-2 (right) IRS Approach Selector Unit to ATT (Attitude) mode, the autopilot disengaged. The ascendancy caster (aileron) again centered and the aircraft began a apathetic cycle to the right. The aural alert, BANK ANGLE, articulate as the aircraft anesthetized 35 degrees appropriate bank. The DFDR abstracts showed that alike afterwards the aircraft had accomplished a coffer bend of 100 degrees, with the bend attitude abutting 60 degrees aircraft adenoids down, the pilot did not cycle the aircraft wings akin afore attempting bend accretion in accordance with accepted procedures. The aircraft accomplished 3. g, as the acceleration accomplished Mach 0. 926 during abiding noseup elevator ascendancy ascribe while still in a appropriate bank. The recorded airspeed exceeded Vdive (400 kcas), and accomplished a best of about 490 kcas aloof above-mentioned to the end of recording. Flight recorder abstracts adumbrated that a cogent structural abortion occurred back the aircraft was at a acceleration of Mach 0. 926 and the flight amount aback and rapidly antipodal from 3. 5g to abrogating 2. 8 g. This g force and airspeed are above the architecture limitations of the aircraft. The aircraft was in a alarmingly uncontrollable accompaniment at that time.
There was no affirmation that the pilots were appropriately authoritative the aircraft, alike afterwards the BANK ANGLE active articulate as the aircraft’s cycle exceeded 35 degrees appropriate bank. This blow resulted from a aggregate of factors including the abortion of the pilots to abundantly adviser the flight instruments, decidedly during the final 2 account of the flight. Preoccupation with a malfunction of the Inertial Reference Arrangement (IRS) absent both pilots’ absorption from the flight instruments and accustomed the accretion coast and coffer bend to go unnoticed.
The pilots did not ascertain and appropriately arrest the coast anon abundant to anticipate blow of control. Technical log (pilot reports) and aliment annal showed that amid October and December 2006, there were 154 alternating defects, anon and alongside accompanying to the aircraft’s Inertial Reference Arrangement (IRS), mostly the larboard (number-1) system. There was no affirmation that AdamAir included basic believability in their Believability Ascendancy Program (RCP) to ensure the capability of the airworthiness of the aircraft apparatus for the agile at the time of the accident.
During the assay the NTSC issued a cardinal of recommendations to the Directorate General Civil Aviation (DGCA) and AdamAir apropos to IRS aliment and training of flight crews in IRS and aircraft agitated recovery. I am admiring to advertise the afterward able absolute assurance actions. AdamAir brash the NTSC and DGCA that it has taken assurance activity to abode the IRS birthmark troubleshooting procedures and aliment blank supervision.
It issued Engineering Orders with instructions and procedures for the appraisal and alteration of repetitive IRS problems, and from November 2007 has had all-encompassing communication with the IRU manufacturer. The assurance activity taken to date by AdamAir includes arena academy and aircraft actor training for pilots to ensure accomplishment in agitated accretion from 14 January 2008. The DGCA brash the NTSC that on 23 November 2007 it issued a Assurance Circular, to all airline operators, acute specific activity to abode deficiencies acclaimed by the NTSC, in accurate the IRS aliment and pilot training deficiencies.
The DGCA requires operators to conduct continuing assay and surveillance of repetitive defects and ensure actual chase up antidotal action. The DGCA has additionally abreast operators that it is actively ecology aircraft defects, in accurate repetitive defects, and back the on-condition base of aliment is accounted to be bereft to annihilate repetitive defects, DGCA will crave basic backup on a hard-time basis.
On 10 March 2008, the DGCA abreast the NTSC that in accession to acute agitated accretion training from 8 January 2008, the DGCA requires operators to accommodate spatial disorientation and its furnishings in their abridgement of antecedent and recurrency training. The DGCA affairs to ensure, through accepted aerial operations inspections, that operators and aerial schools are acknowledging with this requirement. The abode will be accessible on the NTSC web armpit afterwards the media conference: http://www. dephub. go. id/knkt/ntsc_aviation/aaic. htm JAKARTA, 25 MARCH 2008
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