Adam Air Case

MINISTRY OF TRANSPORTATION National Transportation prophylactic commission 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 emailprotected go. id usual RELEASE OF FINAL REPORT PK-KKW FL DHI 574 Today the National Transportation Safety Committee is releasing its final report into the accident involving AdamAir PK-KKW Flight DHI 574 on 1 January 2007.We extend our prayers and condolences to the families of the passengers and crew. The NTSC has reviewed the comments on the draft final report from the related parties in accordance with ICAO Annex 13. Now I am fitting to report to you that as of today, strong and appropriate sentry go exploit had been interpreted during the course of the investigation by the DGCA and AdamAir and Angkasa Pura I, on eight of the el scour recommendations in the report. The last three recomm endations are only being issued today.The Boeing 737, registered PK-KKW, departed from Djuanda Airport, Surabaya at 0559 Coordinated Universal Time (UTC) under the instrument flying rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 0814. There were 102 people on board two polishers, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants. The aircraft disappeared from radar while cruising at 35,000 feet. Following an extensive land, air, and ocean search, wreckage was found in the water and on the shore along the beach near Pare-Pare, Sulawesi 9 days after the aircraft disappeared.Locator beacon signals from the pip recorders were heard on 21 January 2007 and their positions logged. The search was suspended when it was determined that the wreckage was rigid in the ocean at a depth of about 2,000 meters, requiring change date fromy equipment not available in the Region. The salvage operation to recover the publi c life recorders commenced on 24 August 2007 and the Digital Flight information Recorder and Cockpit Voice Recorder were recovered on 27 and 28 August 2007 respectively.The CVR revealed that two pilots were concerned about navigation problems and subsequently became jailed 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 performs. The DFDR analysis showed that the aircraft was in journey at FL 350 with the autopilot engaged. The autopilot was holding 5 degrees left aileron undulate in order to maintain wings-level.Following the crews cream of the number-2 (right) IRS Mode Selector Unit to ATT (Attitude) mode, the autopilot disengaged. The control wheel (aileron) indeed centered and the aircraft began a slow buzz to the right. The aural alert, BANK ANGLE, sounded as the aircraft passed 35 degrees right curse . The DFDR data showed that even after the aircraft had reached a bank angle of 100 degrees, with the chuck attitude approaching 60 degrees aircraft snuggle down, the pilot did not roll the aircraft wings level before attempting pitch recovery in accordance with standard procedures. The aircraft reached 3. g, as the speed reached Mach 0. 926 during continue noseup 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 earlier to the end of recording. Flight recorder data indicated that a significant morphologic failure occurred when the aircraft was at a speed of Mach 0. 926 and the flight load curtly and rapidly reversed from 3. 5g to negative 2. 8 g. This g force and airspeed are beyond the design limitations of the aircraft. The aircraft was in a critically uncontrollable raise at that time.There was no evidence that the pilots were appropriately controlling the aircraft, ev en after the BANK ANGLE alert sounded as the aircrafts 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. absorption 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 exuberant to prevent loss of control. Technical log (pilot reports) and maintenance records showed that between October and celestial latitude 2006, there were 154 recurring defects, directly and indirectly related to the aircrafts Inertial Reference System (IRS), mostly the left (number-1) system. There was no evidence that AdamAir included component reliability in their Reliability Control course of study (RCP) to underwrite the effectiveness of the airworthiness of the aircraft components for the fleet at the time of the accident.During the investigation the NTSC issued a number of recommendations to the Directorate General Civil Aviation (DGCA) and AdamAir relating to IRS maintenance and study of flight crews in IRS and aircraft upset recovery. I am pleased to harbinger the following strong positive safety actions. AdamAir advised the NTSC and DGCA that it has taken safety action to address the IRS defect troubleshooting procedures and maintenance oversight supervision.It issued Engineering Orders with book of instructions and procedures for the evaluation and rectification of repetitive IRS problems, and from November 2007 has had extensive liaison with the IRU manufacturer. The safety action taken to date by AdamAir includes ground school and aircraft simulator training for pilots to go over proficiency in upset recovery from 14 January 2008. The DGCA advised the NTSC that on 23 November 2007 it issued a Safety C ircular, to all airline operators, requiring specific action to address deficiencies noted by the NTSC, in particular the IRS maintenance and pilot training deficiencies.The DGCA requires operators to conduct continuing analysis and surveillance of repetitive defects and ensure immediate follow up corrective action. The DGCA has also informed operators that it is actively monitoring aircraft defects, in particular repetitive defects, and when the on-condition basis of maintenance is deemed to be insufficient to eliminate repetitive defects, DGCA will require component refilling on a hard-time basis.On 10 March 2008, the DGCA informed the NTSC that in addition to requiring upset recovery training from 8 January 2008, the DGCA requires operators to include spatial disorientation and its effects in their syllabus of initial and recurrency training. The DGCA plans to ensure, through bite flying operations inspections, that operators and flying schools are complying with this requireme nt. The report will be available on the NTSC web site after the media conference http//www. dephub. go. id/knkt/ntsc_aviation/aaic. htm JAKARTA, 25 MARCH 2008