Panicky pilots caused jet tragedyFont Size: Decrease Increase Print Page: Print By Stephen Fitzpatrick | March 26, 2008
AN Indonesian jetliner smashed into the ocean, obliterating all trace of its 102 occupants, after its pilots accidentally disengaged the autopilot while they were trying to reset a failed navigational system, an inquiry has found.
The Adam Air Boeing 737 was en route from Surabaya, East Java, to Manado, North Sulawesi, when it foundered on New Year's Day last year.
The investigation details the terrifying final moments as the two inexperienced and poorly trained pilots veered off course in stormy weather, tried to reset their malfunctioning instruments using a guide book that had been downloaded from an unauthorised website and then failed to right the craft as it banked and dived almost 25,000 feet in just over a minute.
The findings probably come too late to affect the company: Adam Air was grounded last week on safety concerns, days after announcing it was insolvent and needed tens of billions of rupiah to continue operating.
The operator, founded by parliamentary speaker Agung Laksono and businesswoman Sandra Ang - and named for her chief executive son Adam, 27, - has a history of going off course at the strategic and operational level.
The pilots of the doomed flight DHI 574 can be heard on the cockpit voice recorder expressing panic that they were heading in the wrong direction and into a violent storm.
The two became so fixated on rectifying the problem that they ignored automated cockpit warnings to take control of the plane as it banked 100 degrees to the right and then pitched 60 degrees forward.
One year previously, an Adam Air flight had veered hundreds of kilometres from its intended route and landed on a little-used airstrip in Sumbawa, eastern Indonesia. Investigations into the instrument failure that caused that incident were criticised as cursory and part of a political cover-up.
A National Transportation Safety Committee senior director Mardjono Siswosuwarno admitted yesterday it was possible the same equipment failure that caused the 2006 incident was behind last year's disaster.
The crashed aircraft's Inertial Reference System, which helps the autopilot system maintain its bearing, had failed multiple times in the months before the disaster, according to Adam Air maintenance records.
However, investigators found senior pilots at the airline were unable to explain how the IRS system worked. Nor did the airline provide training in IRS system failure or in how to right an upset aircraft.
The report notes a range of failings in individual pilot abilities and the airline's training and maintenance regimes.
It suggests the entire industry has a long way to go before an estimated 34 million passengers per annum can fly with any expectation of safety.
Indonesia recently signed a $22 million transport safety assistance package with Australia, and trains with the International Aviation Safety Commission. Last month, it received a surprise award for its air traffic control systems from the prestigious Jane's Airport Review, although a European Union ban remains on Indonesian aircraft flying in its airspace.
Herman Mulyadi, an air force colonel and medical doctor who is also a member of the National Transportation Safety Committee, said yesterday the Adam Air crash should not be regarded as the result of "human error" but rather of "human failing ... because this is one of the risks of flying".
"There was a failure in human performance and to err is human," he said.
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This is basic CRM stuff. Remember the L1011 in the Florida everglades?
Some interesting observation regarding the senior company pilots, too.
