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 supplications and sympathies to the groups of the travelers and team. The NTSC has looked into 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 suitable security move had been made throughout the examination by the DGCA and AdamAir and Angkasa Pura I, on eight of the eleven proposals in the report. The last three proposals are just being given today. The Boeing 737, enlisted 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 group, and 96 travelers involved 85 grown-ups, 7 kids and 4 newborn children. 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 guide signals from the flight recorders were heard on 21 January 2007 and their positions logged. The inquiry was suspended when it was resolved that the destruction was situated in the sea at a profundity of around 2,000 meters, requiring specific recuperation gear not accessible in the Region. The rescue activity to recoup the flight recorders started on 24 August 2007 and the Digital Flight Data Recorder and Cockpit Voice Recorder were recuperated 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) abnormalities for at any rate the most recent 13 minutes of the flight, with insignificant respect to other flight prerequisites. This included recognizable proof and endeavors at restorative activities. The DFDR investigation demonstrated 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 separated. 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 considerably 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 systems. 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 around 490 kcas only preceding the finish of recording. Flight recorder information showed that a huge basic disappointment happened when the airp lane was at a speed of Mach 0. 926 and the flight load unexpectedly and quickly turned around from 3. 5g to negative 2. 8 g. This g power and velocity are past the structure impediments of the airplane. The airplane was in a fundamentally wild state around then. There was no proof that the pilots were properly 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 elements including the disappointment of the pilots to enough 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 identify and fittingly capture the plunge soon enough to forestall loss of control. Specialized log (pilot reports) and support records indicated that among October and December 2006, there were 154 repeating abandons, straightforwardly and by implication identified with the aircraft’s Inertial Reference System (IRS), generally the left (number-1) framework. There was no proof that AdamAir remembered part dependability 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 proposals to the Directorate General Civil Aviation (DGCA) and AdamAir identifying with IRS upkeep and preparing of flight teams in IRS and airplane upset recuperation. I am satisfied to declare the accompanying solid positive wellbeing activities. AdamAir prompted the NTSC and DGCA that it has made security move to address the IRS deformity investigating systems and support oversight management. It gave Engineering Orders with guidelines and methodology for the assessment and amendment of dull IRS issues, and from November 2007 has had broad contact with the IRU producer. The security 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 carrier administrators, requiring explicit activity to address inadequacies noted by the NTSC, specifically the IRS upkeep and pilot preparing lacks. The DGCA expects administrators to lead proceeding with examination and reconnaissance of dreary deformities and guarantee quick follow up restorative activity. The DGCA has likewise educated administrators that it is effectively observing airplane deserts, specifically redundant deformities, and when the on-condition premise of support is esteemed to be inadequate to wipe out dreary imperfections, DGCA will require segment 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 confusion and its belongings for their schedule of introductory and recurrency preparing. The DGCA plans to guarantee, through routine flying activities reviews, that administrators and flying schools are following this necessity. 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