Adam Air B737-400 fatal crash January 2007
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OK, so where are you guys who claimed that SlikAir could ONLY have been an intentional entry?
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Hi Mike Alpha Tango Tango,
Could you please repost the report again, I'm unable to open it. (Don't know why?). Thanks.
>>>AdamAir 737 accident report published
--------------------------------------------------------------------------------
http://www.dephub.go.id/knkt/ntsc_aviation/aaic.htm<<<
Could you please repost the report again, I'm unable to open it. (Don't know why?). Thanks.
>>>AdamAir 737 accident report published
--------------------------------------------------------------------------------
http://www.dephub.go.id/knkt/ntsc_aviation/aaic.htm<<<
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How 2 pilots with 20,000 hours between them forgot to fly the aeroplane is beyond me. They knew the AP has disengaged, they were alerted the aircraft had excessive bank angle and they still farted around with the IRS until way too late.......
Very sad.
Very sad.
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My information on Adam Air is this:
-started 2003 with 2 -400's and a 500;CP was off the -200 as were most of the subsequent intake of pilots.Knowledge of the IRS/FMC was therefore limited.
-Some foreign pilots were employed in a training capacity but only very briefly.The work permits were issued for 1 month only.
-Maintenance was sub-standard.No experienced engineers to oversee start of operations and install a quality control program.Lack of parts.I heard that when they were operating with 3 aircraft,one of the -400's was permanently grounded and used for parts.
-No training department to speak of.No simulator training available.In fact,were these -200 guys ever put on a 3/4/5 TR course?Who knows?I heard that their cadets from flight school did do a full TR in Australia but cant confirm it.
-MEL routinely ignored from the start of operations...
-no auditing(internal/external)
If true,its no surprise that it ended the way it did.However,the real culprit in all this wasn't the airline but the Indonesian CAA who oversaw the whole sorry mess.The same people who refused to believe Silk Air was suicide.
-started 2003 with 2 -400's and a 500;CP was off the -200 as were most of the subsequent intake of pilots.Knowledge of the IRS/FMC was therefore limited.
-Some foreign pilots were employed in a training capacity but only very briefly.The work permits were issued for 1 month only.
-Maintenance was sub-standard.No experienced engineers to oversee start of operations and install a quality control program.Lack of parts.I heard that when they were operating with 3 aircraft,one of the -400's was permanently grounded and used for parts.
-No training department to speak of.No simulator training available.In fact,were these -200 guys ever put on a 3/4/5 TR course?Who knows?I heard that their cadets from flight school did do a full TR in Australia but cant confirm it.
-MEL routinely ignored from the start of operations...
-no auditing(internal/external)
If true,its no surprise that it ended the way it did.However,the real culprit in all this wasn't the airline but the Indonesian CAA who oversaw the whole sorry mess.The same people who refused to believe Silk Air was suicide.
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Hi,
Direct link to the PDF:
http://www.dephub.go.id/knkt/ntsc_av...KW_Release.pdf
Cheers.
Could you please repost the report again, I'm unable to open it. (Don't know why?). Thanks
http://www.dephub.go.id/knkt/ntsc_av...KW_Release.pdf
Cheers.
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As usual the “armchair, after the event pilots” are fast to give us obvious advise, like “fly the airplane,” but it seems to me that there is more to this than stated in the report, and IFixPlanes has highlighted the possible clue.
I am not familiar with the 734, but note from the report that the AP disconnect chime (which lasted for approx 4 seconds, according to the report) was cancelled by one of the pilots. I understand that AP disconnect should indeed have happened once ATT was selected, as it had been, so for TWO reasons the crew should have been aware of AP disconnect – the chime, and systems knowledge.
Now, bearing in mind that the likely flight conditions (according to the report) were marginal VMC, it seems to me to be highly likely that at least one of the crew would have been “flying the airplane” or at the very least monitoring the flight profile, and this is supported by corrections to roll that the report acknowledges did take place at this stage. Furthermore, in my opinion it is very unlikely that at least one crew member would not have responded to the subsequent bank angle warning, so I am therefore drawn to the conclusion that in the early stages of the upset, the crew were indeed monitoring the attitude indications, and controlling the airplane in response to them.
Could it not therefore be the case that in view of IFixPlanes post, the attitude indications they were responding to were actually erroneous? As one unfamiliar with the type in question I am unable to comment further, but 46 seconds is not far off 30 seconds - even for an armchair pilot accident investigator.
I am not familiar with the 734, but note from the report that the AP disconnect chime (which lasted for approx 4 seconds, according to the report) was cancelled by one of the pilots. I understand that AP disconnect should indeed have happened once ATT was selected, as it had been, so for TWO reasons the crew should have been aware of AP disconnect – the chime, and systems knowledge.
Now, bearing in mind that the likely flight conditions (according to the report) were marginal VMC, it seems to me to be highly likely that at least one of the crew would have been “flying the airplane” or at the very least monitoring the flight profile, and this is supported by corrections to roll that the report acknowledges did take place at this stage. Furthermore, in my opinion it is very unlikely that at least one crew member would not have responded to the subsequent bank angle warning, so I am therefore drawn to the conclusion that in the early stages of the upset, the crew were indeed monitoring the attitude indications, and controlling the airplane in response to them.
Could it not therefore be the case that in view of IFixPlanes post, the attitude indications they were responding to were actually erroneous? As one unfamiliar with the type in question I am unable to comment further, but 46 seconds is not far off 30 seconds - even for an armchair pilot accident investigator.
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Originally Posted by sooty615
Could it not therefore be the case that ... the attitude indications they were responding to were actually erroneous?
- Capt´s EADI (data provided by the left IRS)
- F/O´s EADI (data provided by the right IRS)
- standby horizon indicator (attitude is provided by a vertical gyro)
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IFixPlanes, thank you, and indeed I am aware of the fact that there is a standby gyro - perhaps even one that I am currently familiar with that provides not only attitude, but also altitude, Mach, Airspeed and even glide slope information.
As stated in the report, the No2 2 (co-pilot side) primary attitude indications were disabled, and if I have understood your previous post correctly, the No1 side attitude indications would have taken 30 seconds to stabilise. This being the case, the ONLY source of reliable attitude reference would be from the independent standby gyro.
I have observed many situations in the sim of crew following an unreliable flight director / primary attitude indications for quite some time before realising their error only after the aircraft (sim) had gotten well out of shape. In the case of this aircraft upset, only 46 seconds elapsed before it was too late, and initially, as stated in the report, the required corrections to bank angle were not excessive.
Only my humble opinion from observations in the report, but as stated previously I am not familiar with the 734, so stand to be corrected.
As stated in the report, the No2 2 (co-pilot side) primary attitude indications were disabled, and if I have understood your previous post correctly, the No1 side attitude indications would have taken 30 seconds to stabilise. This being the case, the ONLY source of reliable attitude reference would be from the independent standby gyro.
I have observed many situations in the sim of crew following an unreliable flight director / primary attitude indications for quite some time before realising their error only after the aircraft (sim) had gotten well out of shape. In the case of this aircraft upset, only 46 seconds elapsed before it was too late, and initially, as stated in the report, the required corrections to bank angle were not excessive.
Only my humble opinion from observations in the report, but as stated previously I am not familiar with the 734, so stand to be corrected.
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Originally Posted by sooty615
...As stated in the report, the No2 2 (co-pilot side) primary attitude indications were disabled, and if I have understood your previous post correctly, the No1 side attitude indications would have taken 30 seconds to stabilise. This being the case, the ONLY source of reliable attitude reference would be from the independent standby gyro. ...
The right IRS is the sources for the F/O EFIS, so only his system needs to recover.
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Originally Posted by ASFKAP
... I can count the number of IRS failures I've had on one hand, it was/is probably one of the most reliable systems on the aeroplane, I can't understand how this aircraft had over 100 IRS writeups like this....
Originally Posted by Investigation Report
...Line maintenance rectification action was limited to re-racking and swapping IRU positions and associated components, resetting circuit breakers and cleaning connections when the faults became repetitive...
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Report Released
I notice the report was finally released last week:
http://http://www.theage.com.au/news...207086596.html
Any comments?
http://http://www.theage.com.au/news...207086596.html
Any comments?
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Could it not therefore be ... the attitude indications they were responding to were actually erroneous?
____________________________________________________________ _
Especially when dealing w/ systems 'issues' that might impact attitude displays, a pilot MUST ALWAYS verify the validity of their attitude indications the best they can. If they had an operable standby attitude indicator (they should have), it most definitely needed to be utilized in their crosscheck/verification process, and potentially used as primary attitude reference for straight - level flight.
KC135777
____________________________________________________________ _
Especially when dealing w/ systems 'issues' that might impact attitude displays, a pilot MUST ALWAYS verify the validity of their attitude indications the best they can. If they had an operable standby attitude indicator (they should have), it most definitely needed to be utilized in their crosscheck/verification process, and potentially used as primary attitude reference for straight - level flight.
KC135777
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This is not the first time that a crew have been pre-occupied with a failure to such and extent that the pre-occupation was the main causal factor of a crash: http://aviation-safety.net/database/...?id=19721229-0
This is probably one of the most famous accidents.
It is terribly easily done and I would hope that all professional pilots would reflect on this. The trouble with being totally consumed by one issue is that you can not recognize the fact that you are totally consumed by it.
This is probably one of the most famous accidents.
It is terribly easily done and I would hope that all professional pilots would reflect on this. The trouble with being totally consumed by one issue is that you can not recognize the fact that you are totally consumed by it.
OK, so where are you guys who claimed that SlikAir could ONLY have been an intentional entry??
The Adam Air accident report is certainly interesting, but I was slightly disappointed that it seems to focus primarily on the crew's task management in general and (lack of) actions after the autopilot disconnect, leaving some important questions relating to the IRS/FMS behaviour unanswered. I think by focussing mainly on the inappropriate task divisions and flawed upset recovery, the investigators missed an opportunity to shed some new light on the inherent design limitations (or, if you want: deficiencies) of a dual-IRS setup, system knowledge by the crew, and training regarding IRS/FMS/EFIS/AFDS systems.
The aircraft seemed to be off course early during the incident, tracking roughly to DILAM i.s.o. DIOLA, which necessitated a 24 degree corrective turn to the right 13 minutes later (*). The pilots also reported strange wind-readouts, which suggests an erroneous FMC groundspeed (note that the FMC position and groundspeed are normally based on the left IRS position and radio-navigation updates). The investigators wrote: "given the FMC's default selection of the left IRU while on the ground and the large left IRU velocity errors shortly after takeoff, it is probable that the FMC's velocity divergence test determined that the IRU-R was the erroneous IRU. This would preclude the FMC's position difference test (IRU-Radio position > 4nm) from causing the FMC selected IRU to switch to IRU-R." All these observations seem to suggest that the left IRU data was faulty, yet the crew decided to switch the right IRU to ATT. As far as I can see, the report does not attempt to find an explanation for this choice, and in fact it even often refers to "the IRU" with no further specification. At one time during the incident, the crew commented: "now the left one is good, the right one is different, you are kidding". Was there any particular reason for them to reach this conclusion at that particular moment?
The IRS FAULT checklist didn't provide assistance for a partial IRS failure with no FAULT light, as encountered by this crew. This confused them a lot, as evidenced by the comments from the pilots: "It's not fault", "The IRS is erroneous", "But the fault must be illuminated, capt", "It is, it is not fault", etc. 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.
Some time after the crew had switched the IRS-R to ATT, the PIC said "put it back on nav again, put it back on nav again." Once an IRS is switched to ATT, it is impossible to re-align it during flight, so putting it back in NAV is useless. I know it is all too easy to judge the crew for lack of knowledge after the facts, but this is such fundamental knowledge that I'd have expected the accident report to mention this explicitly. As far as I see, it doesn't, missing an opportunity to identify a training deficiency (at least enhancing the argument the report makes about deficient IRS system training and maybe identify lacking training on crew coordination for unrecoverable actions) and perhaps also to improve the IRS FAULT procedure in the QRH.
Crew-coordination during the last few minutes seems to have been negatively influenced by the fact that the copilot lost most of his EADI and EHSI indications. This would have affected his ability to monitor the flight-path (now having to check the indications of the captain and/or stby horizon). As far as I can see, the report doesn't analyse this difficulty, nor does it (counterfactually) highlight that the copilot's displays could have been restored using the IRS transfer switch.
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?
(*) 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 aircraft seemed to be off course early during the incident, tracking roughly to DILAM i.s.o. DIOLA, which necessitated a 24 degree corrective turn to the right 13 minutes later (*). The pilots also reported strange wind-readouts, which suggests an erroneous FMC groundspeed (note that the FMC position and groundspeed are normally based on the left IRS position and radio-navigation updates). The investigators wrote: "given the FMC's default selection of the left IRU while on the ground and the large left IRU velocity errors shortly after takeoff, it is probable that the FMC's velocity divergence test determined that the IRU-R was the erroneous IRU. This would preclude the FMC's position difference test (IRU-Radio position > 4nm) from causing the FMC selected IRU to switch to IRU-R." All these observations seem to suggest that the left IRU data was faulty, yet the crew decided to switch the right IRU to ATT. As far as I can see, the report does not attempt to find an explanation for this choice, and in fact it even often refers to "the IRU" with no further specification. At one time during the incident, the crew commented: "now the left one is good, the right one is different, you are kidding". Was there any particular reason for them to reach this conclusion at that particular moment?
The IRS FAULT checklist didn't provide assistance for a partial IRS failure with no FAULT light, as encountered by this crew. This confused them a lot, as evidenced by the comments from the pilots: "It's not fault", "The IRS is erroneous", "But the fault must be illuminated, capt", "It is, it is not fault", etc. 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.
Some time after the crew had switched the IRS-R to ATT, the PIC said "put it back on nav again, put it back on nav again." Once an IRS is switched to ATT, it is impossible to re-align it during flight, so putting it back in NAV is useless. I know it is all too easy to judge the crew for lack of knowledge after the facts, but this is such fundamental knowledge that I'd have expected the accident report to mention this explicitly. As far as I see, it doesn't, missing an opportunity to identify a training deficiency (at least enhancing the argument the report makes about deficient IRS system training and maybe identify lacking training on crew coordination for unrecoverable actions) and perhaps also to improve the IRS FAULT procedure in the QRH.
Crew-coordination during the last few minutes seems to have been negatively influenced by the fact that the copilot lost most of his EADI and EHSI indications. This would have affected his ability to monitor the flight-path (now having to check the indications of the captain and/or stby horizon). As far as I can see, the report doesn't analyse this difficulty, nor does it (counterfactually) highlight that the copilot's displays could have been restored using the IRS transfer switch.
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?
(*) 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?
Last edited by xetroV; 1st Apr 2008 at 13:55.
Trim
Re the difference in aileron position (report page 28); is there anything odd about a difference of about 2 deg between them with the autopilot engaged and reasonable tracking when disengaged? Larger differences during the descent might be attributed to excessive air loads.
Does the autopilot trim the aileron, or are the crew expected to trim out any hand-wheel offset?
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.
Does the autopilot trim the aileron, or are the crew expected to trim out any hand-wheel offset?
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.