Adam Air B737-400 fatal crash January 2007
Join Date: Nov 2006
Location: Asia
Posts: 183
Likes: 0
Received 0 Likes
on
0 Posts
Aviate, then Navigate, then....
Note: 100% speculation and unfounded hypothesis follows:
punkalouver,
So you think the Captain was already cross-cockpit flying on the F/O's ADI?
Could be.
Makes sense since he wanted to ditch the #1 IRU NAV track errors. The F/O was complaining that the checklist didn't really apply since it assumed you had a WARN/FAULT light identifying the errant laser ring gyro.
So maybe the F/O killed the good side (ATT) and now, when the F/O's ADI blanks/freezes for 30 sec's the Capt wants it and the good NAV source back.... expecting it to return, unaware that the nav position is like an Apollo 13 fuel cell: you squash it and it's history. Capt is yelling for NAV, and the F/O knows he can't go back and restore NAV, but the Capt Yells NAV again, so the F/O yells "NAV!, ok captain!" gives up and does what he's told.
Now what's happening in this speculative scenario?
The F/O looks back down and can tell the captain is no longer flying the airplane but trouble shooting systems, and tries to arrest the roll but is rebuked by a disorientated captain who is still hellbent on saving his NAV data (on punching in a heading into his IRU; which is why he wants a constant heading.)
Problem is that IRU #1 (and ADI #1; cpt's) is precessing wildly and giving both false att info on the left and false heading information (to F/O's HSI#2) and ADI #2 is still unusable waiting for data from IRU 2 to show up.
The only thing possible at this point is full F/O mutiny and flight off the SAI. And after that, They're still going to be lost unless they find some radar!
Now, I hate to bring this up. At two outfits I worked at, the SAI's were in bad shape since they cost a lot to repair...... They would float and drift all over the place. We had to repeatedly pull them back into coherence.
JMHO's.
The above is all just hypothetical speculation only by non-400 qualified old farts and should not be quoted or used for any purpose other than hangar flying.
punkalouver,
So you think the Captain was already cross-cockpit flying on the F/O's ADI?
Could be.
Makes sense since he wanted to ditch the #1 IRU NAV track errors. The F/O was complaining that the checklist didn't really apply since it assumed you had a WARN/FAULT light identifying the errant laser ring gyro.
So maybe the F/O killed the good side (ATT) and now, when the F/O's ADI blanks/freezes for 30 sec's the Capt wants it and the good NAV source back.... expecting it to return, unaware that the nav position is like an Apollo 13 fuel cell: you squash it and it's history. Capt is yelling for NAV, and the F/O knows he can't go back and restore NAV, but the Capt Yells NAV again, so the F/O yells "NAV!, ok captain!" gives up and does what he's told.
Now what's happening in this speculative scenario?
The F/O looks back down and can tell the captain is no longer flying the airplane but trouble shooting systems, and tries to arrest the roll but is rebuked by a disorientated captain who is still hellbent on saving his NAV data (on punching in a heading into his IRU; which is why he wants a constant heading.)
Problem is that IRU #1 (and ADI #1; cpt's) is precessing wildly and giving both false att info on the left and false heading information (to F/O's HSI#2) and ADI #2 is still unusable waiting for data from IRU 2 to show up.
The only thing possible at this point is full F/O mutiny and flight off the SAI. And after that, They're still going to be lost unless they find some radar!
Now, I hate to bring this up. At two outfits I worked at, the SAI's were in bad shape since they cost a lot to repair...... They would float and drift all over the place. We had to repeatedly pull them back into coherence.
JMHO's.
The above is all just hypothetical speculation only by non-400 qualified old farts and should not be quoted or used for any purpose other than hangar flying.
Last edited by pacplyer; 3rd Aug 2008 at 16:17. Reason: numerous changes
Join Date: Nov 2001
Location: Somewhere in the Tropics UTC+7 to 9
Posts: 450
Likes: 0
Received 0 Likes
on
0 Posts
But assuming a functioning SAI
Not all the guys I flew with in later years were even capable of flying without a flight director
But in this case, I wouldn't feel confident in choosing either of these IRU platforms to supply either the attitude reference OR the nav function.
Sounds to me like: This flight was beyond the abilities of most auto-pilot dependent line pilots.
They basically let the aircraft go beyond their own abilities... (you may exchange "their own" with "most/every auto-pilot dependent abilities" though *grin*)...
It certainly doesn't give you much confidence in crews when once again we hear yelling for Allah over and over instead of working to correct the situation. For those tempted to do so in the future, perhaps you could yell "gear down", "speedbrakes" and recovery techniques instead. I guarantee it will provide more help to you and your paying passengers in this life than Allah ever will.
Back to "Allahu Akbar"... was crewing a plane where we said those words but still did not forget the required actions and call them out... we just say "Allahu Akbar" when we could... our self preservation duties comes first, as required by God, whose decision whether to accept our actions of self preservation as sufficient or not, we must submit to... *uurrrghh, that sounds bloody philosophical, but you know what i mean).
Would the airbus aplha protection have prevented/mitigated such occurence?
The F/O looks back down and can tell the captain is no longer flying the airplane but trouble shooting systems, and tries to arrest the roll but is rebuked by a disorientated captain who is still hellbent on saving his NAV data (on punching in a heading into his CDU; which is why he wants a constant heading.)
The only thing possible at this point is full F/O mutiny and flight off the SAI.
Mutiny by the F/O? Well, Adam Air if I remember correctly, imposes an "F/O to assist" culture (old school) not "F/O as delegate" (CRM)... but whether they implemented that after or before this accident, I can't remember (since so many screw ups happened at Adam).
But, I guess management intimidation of "thou shalt obey your seniors and bosses" got into this F/O and defeated his fighter pilot instincts... so, mutiny by F/O was taken out of the equation before the flight even took off... but yes, it was one of the last "easy escape points" available for them.
But the game was up when they heard the "thump thump"... noticed they screamed God's name louder after that...
Now, I hate to bring this up. At two outfits I worked at, the SAI's were in bad shape since they cost a lot to repair...... They would float and drift all over the place. We had to repeatedly pull them back into coherence.
PK-KAR
Join Date: Nov 2006
Location: Asia
Posts: 183
Likes: 0
Received 0 Likes
on
0 Posts
The following is all fiction and opinion just for entertainment purposes only:
PK-KAR:
PK,
Lol! Not making fun of your comment (which is probably true since you know the operators and airplanes better than anyone in that part of the world,) but that seems to be the outlook for everybody these days: Just do NOTHING and it will go away.. in gov, banking, real estate, education, food safety etc.....
But a 75nm (nav unit drift) position error! Yikes!
I know I'm going against the conventional wisdom of "never hand fly when you can keep it coupled up" but we had a small fleet of jets when I started when everytime it rained, the autopilot was unlikely to work much of the night and there was no autothrottle. In fact one month, I hand flew all night for a month at altitude.
(cross cockpit since the instruments were garbage too.)
Man did my flying in the terminal area get good! My scan was superhuman and Captains from real airlines who moonlighted with us couldn't believe that I could often keep the the altimeter on the cpts side parked inside the Zero for hours.
Then at another airline, the "autotrons" took over, Guys in charge of policy who clearly were afraid to hand fly. Their answer to everything was shoe shines and paperwork. The appearance of professionalism, while in reality, no flying skills or systems knowledge were being practiced.
The government tries frequently to stipulate training routines and syllabuses but over the years has sandwiched so many boring videos and regulatory garbage into the ground schools that's there's no time anymore to focus on really knowing the airplane like we used to, imho. Mixed fleet types mean more time should be spent covering differences and less on common sense items; again jmho.
The attitude with most pilots now seems to be: "I don't care how it works. Just tell me what to do when the red light comes on...."
Appalling shift away from science and technology. (Supplanted now with nothing but fear and superstition!)
You're a good man PK, I've followed your stuff for several years now. You're a real asset to aviation safety. Best wishes for you and your country.
PK-KAR:
Disagree... autodependent line pilots could have survived if they knew what to do... which was NOTHING! (and grab the raw data)... do what the other guys did... just write up the IRS pos displacement after the flight (45NM... yeah, there was a 75NM a few days before, and one last year (on another airline)...)... they lived.
Lol! Not making fun of your comment (which is probably true since you know the operators and airplanes better than anyone in that part of the world,) but that seems to be the outlook for everybody these days: Just do NOTHING and it will go away.. in gov, banking, real estate, education, food safety etc.....
But a 75nm (nav unit drift) position error! Yikes!
I know I'm going against the conventional wisdom of "never hand fly when you can keep it coupled up" but we had a small fleet of jets when I started when everytime it rained, the autopilot was unlikely to work much of the night and there was no autothrottle. In fact one month, I hand flew all night for a month at altitude.
(cross cockpit since the instruments were garbage too.)
Man did my flying in the terminal area get good! My scan was superhuman and Captains from real airlines who moonlighted with us couldn't believe that I could often keep the the altimeter on the cpts side parked inside the Zero for hours.
Then at another airline, the "autotrons" took over, Guys in charge of policy who clearly were afraid to hand fly. Their answer to everything was shoe shines and paperwork. The appearance of professionalism, while in reality, no flying skills or systems knowledge were being practiced.
The government tries frequently to stipulate training routines and syllabuses but over the years has sandwiched so many boring videos and regulatory garbage into the ground schools that's there's no time anymore to focus on really knowing the airplane like we used to, imho. Mixed fleet types mean more time should be spent covering differences and less on common sense items; again jmho.
The attitude with most pilots now seems to be: "I don't care how it works. Just tell me what to do when the red light comes on...."
Appalling shift away from science and technology. (Supplanted now with nothing but fear and superstition!)
You're a good man PK, I've followed your stuff for several years now. You're a real asset to aviation safety. Best wishes for you and your country.
Last edited by pacplyer; 4th Aug 2008 at 06:26. Reason: added: (nav unit drift)
Adam Air recording 'not original' - Jakarta Post
From The Jakarta Post, 4 Aug 08
Adam Air recording 'not original'
The Jakarta Post, Jakarta
Transportation Minister Jusman Syafii Djamal on Saturday confirmed the widely circulated recording of a conversation from the cockpit of the Adam Air jetliner that crashed in the waters off Sulawesi last year was not authentic.
"The recording currently in circulation is not authentic and is not the original," said Jusman in his message to the ministry's spokesman Bambang S. Ervan, as quoted by Antara.
A five-minute-38-second digital recording allegedly retrieved from the plane's blackbox flight recorder, captures the final minutes before Adam Air flight KI 574 crashed into the sea off Majene regency. It has been widely circulated on the Internet and transcribed by the media.
All 102 passengers and crew aboard the Boeing 737-300 were killed in the Jan. 1, 2007, crash. The plane, registered as PK-KKW, departed from Djuanda airport in Surabaya for Manado, North Sulawesi. However, the plane disappeared off the radar a few hours later while cruising at 35,000 feet.
Jusman said the authentic recording, captured on tape and stored by the National Air Transportation Safety Commission (KNKT) inside a closed box, was a "secret documentation". Jusman is the former head of the KNKT.
"If there are any other parties spreading and listening to the recording without expert supervision, it could lead to the public being misinformed," he said, adding plane crash scenarios were not determined by cockpit recordings alone.
"Please respect the KNKT. The complete and comprehensive report of the crash is available at the enter website."
In March this year, the KNKT published its report into the crash, which it blamed on pilot error and navigational equipment malfunctions. The report claimed the pilots were preoccupied with the system malfunction and failed to detect and appropriately correct the plane's descent in time.
However, public attention over the last few days has focused on the leaked recording, believed to be a conversation between pilot Reffi Agustian Widodo and copilot Yoga Susanto, minutes before the crash.
KNKT spokesman J.A. Barata expressed regret over the leaked cockpit conversation recording.
"Even if the recording is real, the incident is already a crime. Annex 13 of the International Civil Aviation Organization (ICAO) convention stipulates such recordings are not to be publicized," he said.
Barata added the incident was the latest in a long list of national aviation fiascoes, following last year's ban by the European Union on Indonesian airlines from flying into the EU after a series of domestic air accidents.
Adam Air recording 'not original'
The Jakarta Post, Jakarta
Transportation Minister Jusman Syafii Djamal on Saturday confirmed the widely circulated recording of a conversation from the cockpit of the Adam Air jetliner that crashed in the waters off Sulawesi last year was not authentic.
"The recording currently in circulation is not authentic and is not the original," said Jusman in his message to the ministry's spokesman Bambang S. Ervan, as quoted by Antara.
A five-minute-38-second digital recording allegedly retrieved from the plane's blackbox flight recorder, captures the final minutes before Adam Air flight KI 574 crashed into the sea off Majene regency. It has been widely circulated on the Internet and transcribed by the media.
All 102 passengers and crew aboard the Boeing 737-300 were killed in the Jan. 1, 2007, crash. The plane, registered as PK-KKW, departed from Djuanda airport in Surabaya for Manado, North Sulawesi. However, the plane disappeared off the radar a few hours later while cruising at 35,000 feet.
Jusman said the authentic recording, captured on tape and stored by the National Air Transportation Safety Commission (KNKT) inside a closed box, was a "secret documentation". Jusman is the former head of the KNKT.
"If there are any other parties spreading and listening to the recording without expert supervision, it could lead to the public being misinformed," he said, adding plane crash scenarios were not determined by cockpit recordings alone.
"Please respect the KNKT. The complete and comprehensive report of the crash is available at the enter website."
In March this year, the KNKT published its report into the crash, which it blamed on pilot error and navigational equipment malfunctions. The report claimed the pilots were preoccupied with the system malfunction and failed to detect and appropriately correct the plane's descent in time.
However, public attention over the last few days has focused on the leaked recording, believed to be a conversation between pilot Reffi Agustian Widodo and copilot Yoga Susanto, minutes before the crash.
KNKT spokesman J.A. Barata expressed regret over the leaked cockpit conversation recording.
"Even if the recording is real, the incident is already a crime. Annex 13 of the International Civil Aviation Organization (ICAO) convention stipulates such recordings are not to be publicized," he said.
Barata added the incident was the latest in a long list of national aviation fiascoes, following last year's ban by the European Union on Indonesian airlines from flying into the EU after a series of domestic air accidents.
Join Date: Nov 2006
Location: Asia
Posts: 183
Likes: 0
Received 0 Likes
on
0 Posts
Interesting.
Nobody used the word fraud did they?
And it showed up what? Almost half a year after the investigation was over? Sounded more like an implied threat against whoever leaked it. Sorta sounds like they don't know how it got out. One official says it's not an authentic recording but the other one implies it was secret documentation and a crime may have been committed.
Well which is it? It can't be both can it?
I'm guessing the "authentic" recording is actually 30 minutes long if it was repeating loop tape or more likely over 2hrs long if it was digital. Five plus minutes wouldn't constitute an "original" would it?
Interesting choice of words.
I agree it's unfortunate that the tape was released to the lay public if that's what happened. But, it's like the downing street memos combined with the 911 commission report. Once they are public knowledge, It's not secret any more. It's out there in the public domain and is fair game to combine the two together and to comment on. Common readers like us can't prevent accident materials from finding their way onto the internet.
My posts could all be wrong. But all things considered, it seems to me a pattern has developed of global pilot pushing where on the one hand you won't let them stay current and hand fly manual climbs, descents and landings via the tyranny of SOP's and automation standardization, and on the other hand you then blame them for accidents when the autopilot craps out.
Seems very counter-intuitive to me; but maybe I just don't see the big picture. I really wish Senator John Glenn or somebody would call me up and explain it to me.....
JMHO's
Nobody used the word fraud did they?
And it showed up what? Almost half a year after the investigation was over? Sounded more like an implied threat against whoever leaked it. Sorta sounds like they don't know how it got out. One official says it's not an authentic recording but the other one implies it was secret documentation and a crime may have been committed.
Well which is it? It can't be both can it?
I'm guessing the "authentic" recording is actually 30 minutes long if it was repeating loop tape or more likely over 2hrs long if it was digital. Five plus minutes wouldn't constitute an "original" would it?
Interesting choice of words.
I agree it's unfortunate that the tape was released to the lay public if that's what happened. But, it's like the downing street memos combined with the 911 commission report. Once they are public knowledge, It's not secret any more. It's out there in the public domain and is fair game to combine the two together and to comment on. Common readers like us can't prevent accident materials from finding their way onto the internet.
My posts could all be wrong. But all things considered, it seems to me a pattern has developed of global pilot pushing where on the one hand you won't let them stay current and hand fly manual climbs, descents and landings via the tyranny of SOP's and automation standardization, and on the other hand you then blame them for accidents when the autopilot craps out.
Seems very counter-intuitive to me; but maybe I just don't see the big picture. I really wish Senator John Glenn or somebody would call me up and explain it to me.....
JMHO's
Pacplyer
It ain't the blame that counts, rather it's the corrective action.
I agree that some in this thread have used some rather strong words about the pilots. Perhaps true descriptions but I read right over them and said to myself Whose at fault ?
We can't always make perfect planes anymore than then perfect pilots. We need to make both tollerant of each other.
OK the report is out, but what is gonna be done about it?
It ain't the blame that counts, rather it's the corrective action.
I agree that some in this thread have used some rather strong words about the pilots. Perhaps true descriptions but I read right over them and said to myself Whose at fault ?
We can't always make perfect planes anymore than then perfect pilots. We need to make both tollerant of each other.
OK the report is out, but what is gonna be done about it?
Join Date: Nov 2006
Location: Asia
Posts: 183
Likes: 0
Received 0 Likes
on
0 Posts
Exactly loma, there's enough blame to go around for everybody.
Since you asked, I'll tell you my opinion what has to happen. It is unrealistic, and unreasonable to expect that the culture should transform itself into a Euro or ICAO dream state overnight. But clearly, for everyone involved to concur to lift the bans, a large-scale sea change has to be evident in Jakarta to regain credibility in the eyes of the worlds regulatory bodies. Otherwise they aren't going to be inclined to stick their necks out.
That change could readily happen if the current administration would allow an outside consulting team to come in and direct an overhaul of the badly needed aviation transportation sector in Indonesia. It doesn't have to be a painful experience. Since there's been numerous 737 problems I know a former Boeing test pilot who used to really enjoy training airline check captains on the 737 and set up large scale airline training programs. He has run multiple flight test programs on too many aircraft to list here including the B-2, U-2, KC135, KC10 and is an examiner on many fighters and test birds in the NASA fleet. He's now a big wheel at Lockheed and the USAFR but said he would help out if asked. His resume is something no one believes when they read it. It is about four pages long and includes presidential aircraft work. A guy like that pulling in like individuals would provide instant credibility and be able to steer some good vibes from boeing and other movers in the industry.
This is what is needed imho.
Since you asked, I'll tell you my opinion what has to happen. It is unrealistic, and unreasonable to expect that the culture should transform itself into a Euro or ICAO dream state overnight. But clearly, for everyone involved to concur to lift the bans, a large-scale sea change has to be evident in Jakarta to regain credibility in the eyes of the worlds regulatory bodies. Otherwise they aren't going to be inclined to stick their necks out.
That change could readily happen if the current administration would allow an outside consulting team to come in and direct an overhaul of the badly needed aviation transportation sector in Indonesia. It doesn't have to be a painful experience. Since there's been numerous 737 problems I know a former Boeing test pilot who used to really enjoy training airline check captains on the 737 and set up large scale airline training programs. He has run multiple flight test programs on too many aircraft to list here including the B-2, U-2, KC135, KC10 and is an examiner on many fighters and test birds in the NASA fleet. He's now a big wheel at Lockheed and the USAFR but said he would help out if asked. His resume is something no one believes when they read it. It is about four pages long and includes presidential aircraft work. A guy like that pulling in like individuals would provide instant credibility and be able to steer some good vibes from boeing and other movers in the industry.
This is what is needed imho.
Last edited by pacplyer; 4th Aug 2008 at 17:42. Reason: punctuation, sentence structure
Join Date: Nov 2004
Location: Here, there, and everywhere
Posts: 1,124
Likes: 0
Received 12 Likes
on
7 Posts
How about letting expats from the west do the flying. Guaranteed to improve your safety record and save lives. That's what Korean and China Airlines partially did when their records were horrible.
Safety first, politics second.
Safety first, politics second.
That change could readily happen if the current administration would allow an outside consulting team to come in and direct an overhaul of the badly needed aviation transportation sector in Indonesia
I don't have a horse to ride in this myself, but I do appreciate seeing positive movement from all rather than backward glances.
I couple of posts hint at words like "allow" and "let us"
That to me suggests that goverment bureacracy has been standing in the way. If that's the problem than ICAO would be correct in pointing to the rest of the world to avoid all of these operators until the goverment oversight is fixed.
If that is not the case and instead it is short cutting training by the operators, then outside help should be offered.
Join Date: Aug 2007
Location: Alabama
Age: 58
Posts: 366
Likes: 0
Received 0 Likes
on
0 Posts
How about letting expats from the west do the flying. Guaranteed to improve your safety record and save lives. That's what Korean and China Airlines partially did when their records were horrible.
Indonesia Adam Air B737-400 fatal crash January 2007
https://en.wikipedia.org/wiki/Adam_Air_Flight_574
Worth re-reading and a good reason for unusual attitude training during type rating training.
Worth re-reading and a good reason for unusual attitude training during type rating training.
