PPRuNe Forums - View Single Post - Adam Air B737-400 fatal crash January 2007
Old 7th Apr 2008, 16:54
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PK-KAR
 
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Was there any particular reason for them to reach this conclusion at that particular moment?
None, according to one of the investigators I had coffee with over the weekend... It was lack of understanding of the system.

As far as I see, the report does not attempt to analyse the suitability of this QRH procedure, or try to establish if the assistence offered by the QRH is sufficient for such failures.
Well, better ask Adam Air why no copy of the QRH specific for the aircraft was available... the only copy unique to KKW only existed on KKW... and the copy available elsewhere, are generic QRH. They cannot question based on lack of evidence. The lack of IRS training also led to possibilities of them not identifying the correct reference in the QRH.

And finally, if the left (not the right) IRS was causing the navigation troubles, can we really be sure that the Euler angles (pitch, roll and heading) of this remaining left IRS were indeed accurate?
I think there is a passage that referred to this...

A related question that remains unanswered: why did the air traffic controller who exclaimed: "Where is Adam direct to? My God, he is flying north!" not inform the pilots straightaway? Why did it take 13 minutes before ATC questioned the aircraft's heading?
The quality of the radar at Makassar ATC is also under question, in that it had not been calibrated when it should have.

The line of thought is that there might have been some residual aileron trim which could add some confusion to a disorientating situation; crews normally expect zero roll rate to equate with zero force.
In addition to xetroV's response, with Adam Air's maintenance records and techlogs, whatever record remains could have been doctored after the accident, there were allegations on this circling around based on testimony of an engineer who alleged he was forced to doctor the records. There are however, no attempts by anyone to confirm this and it is unknown if the NTSC also received information regarding this allegation.

In the AdamAir AAR, can you find anything about SPEEDBRAKES??? Were they kept RETRACTED?
The AAR focused on what precipitated the upset. But, as far as I know from the report (or other info), speedbrakes were down and thrust not retarded to idle. *yikes*

Basically the report focused on the prevalent deficiencies that were so general that led to the series of lack of actions that could have prevented the upset from becoming a high speed water impact. The DATC (Directorate of Air Transport Certification) is now under severe criticism from the NTSC, DGAC, Department of Communications, and the office of the President, for letting this happen. There are also recommendations sent to the DGAC and DATC from the NTSC that were not made public as it was sent separate to the report highlighting the gross deficiencies in the DATC in safety and certification oversight.

The report may be deficient for some readers, but the implications for the DATC is huge. The head of the DGCA and DATC has been trying to reform the DATC and clean it up, but the "internal status quo" forces are too great, and this report, I can guess, is rather politicized in that it is aimed at getting the people in the DATC to clean up, or face criminal charges for negligence, manslaughter or corruption. The Garuda 200 report already managed to force the DATC to accept that it needs more training (with the assistance of Govt. of Japan, and Australia), and this report now brings attention to the "status quo" forces within the DATC that their days of the old habits are over.

Some airline crew are already challenging DATC inspectors on ramp checks and some have sent inspectors off the aircraft with tails between the legs for "inadequate knowledge" after the inspectors try to be smartasses and failed miserably.

Now, if the DATC cannot clean up quickly, the DGAC will let some heads roll within the DATC, which has been "requested" by the president.

Airlines are now split. Some have decided to stay one step ahead of the DATC in terms of application of safety systems, procedures etc, while some have adopted to maintain the status quo and monitor the developments... it'll be very interesting times when the DATC have moved ahead and some of the airlines (read: the usual suspects) stay in the same gear... will the DATC and DGAC be able to show their teeth then?

Interesting times ahead...

PK-KAR
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