Adam Air Case

Service OF TRANSPORTATION National Transportation Safety 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 : [emailâ protected] go. id PUBLIC RELEASE OF FINAL REPORT †PK-KKW †FL DHI 574 Today the National Transportation Safety Committee is discharging its last report into the mishap including AdamAir PK-KKW Flight DHI 574 on 1 January 2007. We stretch out our petitions and sympathies to the groups of the travelers and team. The NTSC has inspected the remarks on the draft last report from the related gatherings as per ICAO Annex 13. Presently I am ready to answer to you that starting today, solid and proper wellbeing move had been made over the span of the examination by the DGCA and AdamAir and Angkasa Pura I, on eight of the eleven suggestions in the report. The last three proposals are just being given today. The Boeing 737, enrolled PK-KKW, left from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an expected time of appearance (ETA) at Sam Ratulangi Airport, Manado of 08:14. There were 102 individuals ready; two pilots, 4 lodge team, and 96 travelers contained 85 grown-ups, 7 kids and 4 babies. The airplane vanished from radar while cruising at 35,000 feet. Following a broad land, air, and ocean search, destruction was found in the water and on the shore along the coast close Pare-Pare, Sulawesi 9 days after the airplane vanished. Locator reference point signals from the flight recorders were heard on 21 January 2007 and their positions logged. The hunt was suspended when it was resolved that the destruction was situated in the sea at a profundity of around 2,000 meters, requiring particular recuperation gear not accessible in the Region. The rescue activity to recuperate the flight recorders started on 24 August 2007 and the Digital Flight Data Recorder and Cockpit Voice Recorder were recouped on 27 and 28 August 2007 individually. The CVR uncovered that the two pilots were worried about route issues and in this manner got engaged with inconvenience shooting Inertial Reference System (IRS) inconsistencies for in any event the most recent 13 minutes of the flight, with insignificant respect to other flight necessities. This included recognizable proof and endeavors at remedial activities. The DFDR examination indicated that the airplane was in journey at FL 350 with the autopilot locked in. The autopilot was holding 5 degrees left aileron wheel so as to keep up wings-level. Following the crew’s determination of the number-2 (right) IRS Mode Selector Unit to ATT (Attitude) mode, the autopilot withdrew. The control wheel (aileron) at that point focused and the airplane started a moderate move to one side. The aural alarm, BANK ANGLE, sounded as the airplane passed 35 degrees right bank. The DFDR information demonstrated that much after the airplane had arrived at a bank point of 100 degrees, with the pitch demeanor moving toward 60 degrees airplane nose down, the pilot didn't roll the airplane wings level before endeavoring contribute recuperation understanding with standard methods. The airplane arrived at 3. g, as the speed arrived at Mach 0. 926 during supported noseup lift control input while still in a correct bank. The recorded velocity surpassed Vdive (400 kcas), and arrived at a limit of roughly 490 kcas only preceding the finish of recording. Flight recorder information demonstrated that a noteworthy basic disappointment happened when the airplane was at a speed of Mach 0. 926 and the flight load out of nowhere and quickly turned around from 3. 5g to negative 2. 8 g. This g power and velocity are past the plan confinements of the airplane. The airplane was in a basically wild state around then. There was no proof that the pilots were fittingly controlling the airplane, much after the BANK ANGLE alert sounded as the aircraft’s roll surpassed 35 degrees right bank. This mishap came about because of a mix of components including the disappointment of the pilots to satisfactorily screen the flight instruments, especially during the last 2 minutes of the flight. Distraction with a breakdown of the Inertial Reference System (IRS) occupied both pilots’ consideration from the flight instruments and permitted the expanding plummet and bank edge to go unnoticed. The pilots didn't recognize and suitably capture the plummet soon enough to forestall loss of control. Specialized log (pilot reports) and support records demonstrated that among October and December 2006, there were 154 repeating surrenders, legitimately and in a roundabout way identified with the aircraft’s Inertial Reference System (IRS), for the most part the left (number-1) framework. There was no proof that AdamAir remembered part unwavering quality for their Reliability Control Program (RCP) to guarantee the adequacy of the airworthiness of the airplane segments for the armada at the hour of the mishap. During the examination the NTSC gave various suggestions to the Directorate General Civil Aviation (DGCA) and AdamAir identifying with IRS support and preparing of flight teams in IRS and airplane upset recuperation. I am satisfied to declare the accompanying solid positive security activities. AdamAir exhorted the NTSC and DGCA that it has made wellbeing move to address the IRS deformity investigating methods and upkeep oversight management. It gave Engineering Orders with directions and techniques for the assessment and correction of tedious IRS issues, and from November 2007 has had broad contact with the IRU producer. The wellbeing activity taken to date by AdamAir incorporates ground school and airplane test system preparing for pilots to guarantee capability in upset recuperation from 14 January 2008. The DGCA prompted the NTSC that on 23 November 2007 it gave a Safety Circular, to all aircraft administrators, requiring explicit activity to address inadequacies noted by the NTSC, specifically the IRS upkeep and pilot preparing insufficiencies. The DGCA expects administrators to lead proceeding with examination and observation of dreary deformities and guarantee quick follow up remedial activity. The DGCA has additionally educated administrators that it is effectively checking airplane abandons, specifically tedious deformities, and when the on-condition premise of upkeep is regarded to be lacking to take out redundant imperfections, DGCA will require part substitution on a difficult time premise. On 10 March 2008, the DGCA educated the NTSC that notwithstanding requiring upset recuperation preparing from 8 January 2008, the DGCA expects administrators to remember spatial bewilderment and its belongings for their prospectus of beginning and recurrency preparing. The DGCA plans to guarantee, through routine flying activities examinations, that administrators and flying schools are consenting to this prerequisite. The report will be accessible on the NTSC site after the media meeting: http://www. dephub. go. id/knkt/ntsc_aviation/aaic. htm JAKARTA, 25 MARCH 2008