Adam Air B737-400 fatal crash January 2007

[Ptkay]

http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final_Report_PK-KKW_Release.pdf

[angels]

According to the Reuters report the plane had 154 recurring defects related to the navigation system in the two months before the crash.

With what's left of their fleet grounded (over half their planes have been seized due to non-payment of debts to the leasing firm), one assumes this is the end for Adam Air.

Probably not a bad thing.

[IFixPlanes]

According to the Reuters report the plane had 154 recurring defects related to the navigation system in the two months before the crash.Please read the linked Report above.
Most of the press could not interpret accident reports.
...
· PIC's vertical speed indicator malfunctions (52 write-ups).
· Left/right inertial reference system anomalies (51 write-ups).
· Illumination of flight data recorder inoperative light (14 write-ups).
· Autopilot A disengage (4 write-ups).
· Weather radar unreliable (2 write-ups).
· Left flight director unserviceable (2 write-ups).
...

[jbsharpe]

Humble SLF with potentially stupid question alert..

How serious a problem was the IRS failure? The report describes the situation the pilots were trying to resolve as 'stressful' (p97 of the PDF, page '83' by the numbering). Was this a problem that was perilous for the safe outcome of the flight, or merely an inconvenience?

JBS

[IGh]

Reading this AAR smacks of so many upset cases over decades, here are some excerpts:

= = = \/ = = = EXCERPT AAR pg 49+ = = = \/ = = =


“… During cruise, the pilot in command (PIC) and copilot became preoccupied with the aircraft’s Inertial Reference System (IRS) and associated failures of the flight and navigation instruments.

The pilots devoted their attention to resolving the apparent anomalies with the IRS for up to 28 minutes prior to switching the number-2 IRS Mode Selector Unit to ATT (Attitude). Initially, they were concerned that one of the Inertial Reference Unit’s (IRU) had failed, and they attempted to identify the problem. … Both pilots became fully engrossed with identifying the problem and attempts at corrective actions for at least the last 13 minutes of the flight, with minimal regard to other flight requirements.

The DFDR showed that the aircraft was in cruise with the autopilot engaged at FL350. The autopilot was holding 5 degrees left aileron to maintain wings level flight. Following the crew’s selection of the IRS Mode Selector Unit to Attitude mode, the autopilot disengaged.

When ATT (Attitude) was selected in the number-2 IRS Mode Selector Unit, it resulted in the autopilot disengaging. The effect on the copilot’s electronic attitude display indicator (EADI) of switching from NAV to ATT was that the following displays were lost …

With the autopilot disengaged, the control wheel (aileron) centered and the aircraft began a slow roll to the right. Although the roll rate was momentarily arrested several times, the pilot did not begin to recover the roll attitude until the aircraft had reached a bank angle of 100 degrees, with the pitch attitude approaching 60 degrees aircraft nose down. At that point the aircraft had already accelerated past Mmo (0.82) and was reaching dive Mach number of 0.89. The overspeed warning activated at Mach 0.82. After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.

The DFDR revealed that after the aircraft reached a dive Mach number of 0.89, the pilot began to roll the aircraft towards wings level, using a bank angle of less than 20 degrees (aileron). During this roll, the pilot pulled nose-up elevator in excess of 2gs of force. The g forces eventually reached 3.5gs as the Mach number reached a maximum of 0.926. The 3.5g force and Mach 0.926 airspeed are beyond the designed limitations …

The recorded airspeed exceeded Vdive (400 kcas), and reached a maximum of approximately 490 kcas just prior to the end of recording. At an altitude of approximately 12,000 feet, the normal load factor suddenly and rapidly reversed from around positive 3.5g to negative 2.8g.

The Boeing analysis suggested that:
This sudden change in load factor is an indication that the airplane has suffered a significant structural failure. The condition of 3.5g’s at 495 knots is well beyond the certified flight maneuvering envelope for generating loads for structural design and outside the envelope ...

= = = /\ = = = END excerpt = = = /\ = = =

This is a typical jet upset, yawXroll=dive; subtle entry, DIVE, increased IAS yield G's, maybe pilot pulls more back-stick to counter IAS .... Sometimes they impact; sometimes inflight break-up, sometimes a recovery (Captain Lynch and Captain Gibson).

OK, so where are you guys who claimed that SlikAir could ONLY have been an intentional entry??

[SmileAirlines]

IRS is a navigational system that feed data into FMS. It's based on gyros, unlike the satellite-based GPS system.

I do believe the plane involved only has IRS, and the autopilot uses FMS and IRS as navigational tools. If the IRS is faulty then the autopilot is "tricked" into flying to the wrong position.

IRS failure is not something perilous if the crew knew how to deal with it... There are other navigational sources available to substitute it, like the VOR, DME, NDB, etc..

JA

[PK-KAR]

Thanks to the NTSC for literally putting it all on the record.
What was said in August-September2006, many refused to believe...
Inadequate training, poor standards, poor maintenance, you name it...
It's now official...
These things happened!

I hope this is a wake up call to the naughty carriers that, in the end, the price of safety is the price you put on the value of the lives on board your jet...

I hope many now realize that such a price of 40USD per life is too low (those who read the "flying circus" thread will know what this means...

I do believe the plane involved only has IRS, and the autopilot uses FMS and IRS as navigational tools. If the IRS is faulty then the autopilot is "tricked" into flying to the wrong position.
The error became so bad that even radio nav input wouldn't help much... Basically, they lost orientation... and the rest is history... and I hope that includes the history of poor inadequate training, no copy of the QRH on board, no FCOM revisions, and the use of "training purposes FCOM" as FCOMs.

At least the "clean contacts, self test, problem solved" method of maintaining the IRS to deal with repeated problems was exposed... *grin*

PK-KAR

[757_Driver]

Its a timely reminder that no matter what else is occuring, No1 priority is - Fly the airplane.

I'm not one to criticize the actions of fellow pilots, as I'm sure what they did made sense at the time. However one thing surprises me - 'rolling before pulling' is something ingrained in basic flight training. I have done a number of 'unusual attitude' recovery sessions, (PPL, CPL, MEP, IR, Jet upset course) as I suspect we all have and everyone said the same - roll level before you pull otherwise you've got a good chance of pulling the aircraft apart.

[cfmoose]

Hi, first post, not in the profession so be merciful, but wanted to have a general dig at media coverage of the final accident report.

http://news.sky.com/skynews/article/0,,30200-1310511,00.html
Sky, in their sensationalist element, have accompanied this article with tenuously-related pictures of a Garuda crash, no doubt in the absence of any gory pics of the incident in question.

What bothered me was this line:
'An investigator said the plane was travelling at 10 times the normal landing speed when it hit the water and would have broken up on impact'.

Surely the landing speed of a 737 is more than 49kts?! :eek:

[IFixPlanes]

:(
http://img231.imageshack.us/img231/2448/adamqrhjv4.jpg

[Brian Abraham]

OK, so where are you guys who claimed that SlikAir could ONLY have been an intentional entry?
Could it have been because the recorders some how "failed" a short (very short) time prior? Connect the dots.

[Lee]

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<<<

[Octane]

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.

[Rananim]

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.

[NotPilotAtALL]

Hi,

Could you please repost the report again, I'm unable to open it. (Don't know why?). Thanks

Direct link to the PDF:

http://www.dephub.go.id/knkt/ntsc_aviation/baru/Final_Report_PK-KKW_Release.pdf

Cheers.

[IFixPlanes]

@Lee
be patient. The Downloadrate is 1,5 to 2 KB/sec.

[Lee]

NotPilotAtAll and IFixPlanes

Thanks to both of you, I managed to download the report.

Yes, patience is a virtue.

[sooty615]

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.

[IFixPlanes]

Could it not therefore be the case that ... the attitude indications they were responding to were actually erroneous?
In the 737 you have 3 different sources for attitude:
- 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)

[sooty615]

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.

[IFixPlanes]

...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. ...

No, only the system which is switched to ATT needs several seconds until attitude displays recover.
The right IRS is the sources for the F/O EFIS, so only his system needs to recover.

[IFixPlanes]

... 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....

Maybe this sentence out of the Investigation Report will help you to anderstand:
...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...:ugh::ugh::ugh:

[IFixPlanes]

@ IGh
If you use the Quote-Funktion it would be readable.:ugh:
At the moment it is only a "copy paste" mess!
Can you point out in a shorter way what you want to tell?

[malcolmyoung90]

I notice the report was finally released last week:

http://http://www.theage.com.au/news/news/pilots-blamed-for-new-years-adam-air-crash/2008/03/25/1206207086596.html

Any comments?

[jbsharpe]

Report thread:

http://www.pprune.org/forums/showthread.php?t=319588

:ok:

[KC135777]

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

[fmgc]

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/record.php?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.

[Centaurus]

OK, so where are you guys who claimed that SlikAir could ONLY have been an intentional entry??

As someone present at a court case in Singapore pertaining to the Silk Air "accident" I can assure you the evidence presented revealed the weather in the area of the accident was strictly fine and sunny and there was no evidence there was any thing wrong with that aeroplane except the suspected deadly intentions of the pilot in command. Read the report for yourself rather than make an uninformed outburst on Pprune.

[xetroV]

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?

[alf5071h]

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.

[IGh]

An observation from “xetroV”, in message #32 on 1Apr, regarding pilots’ analysis of a faulty IRU [when designers provided ONLY two IRUs for those mishap pilots to compare]:

-- [from 2nd paragraph] “... 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 ...”

-- from 4th paragraph] “... 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....”

Those are good points.

Question inferred from xetroV’s observations:

Wouldn’t a THIRD IRU have aided these mishap pilots?

The 3rd IRU could have aided their fault analysis, and [with proper design switching] the PITCH and ROLL signals from the 3rd IRU could have been selected, or de-selcted, to either PFD. This design, with the 3rd IRU, would be analogous to the better AUX GYRO switching we used before abandoning the VGs (later B737 designs use only 2 IRUs).

[xetroV]

In-flight rudder and/or aileron trim adjustments are not uncommon for the B737, especially as flap/slat rigging appears to be some kind of black art. I know one particular aircraft that requires left aileron for flaps 5, right aileron for flaps 15, and finally left aileron for flaps 30...

Aileron trim should not be used when the autopilot is engaged, as the autopilot will overpower the trim, which may result in an out of trim condition after autopilot disengagement. However, an out of trim condition will also occur after AP disengagement if the aircraft is, well, out of trim. :) The AP can easily mask out-of-trim situations if you don't pay close attention to the exact control wheel position during cruise.

Primary rudder trim technique is to fly the airplane (AP engaged) straight & level in HDG SEL and trim the rudder to the down-side of the control wheel until the wheel is level. Some forward slip is then deemed acceptable. The secondary rudder trim technique is to use rudder-trim until the bank angle is zero. In this case, the airplane may have a rolling tendency when the autopilot is disengaged; aileron trim can then be used to trim out the remaining control wheel forces.

In my experience, the primary technique is usually effective, but rudder trim deflections of up to one unit are not unheard of. This is after all how aircraft were made in the '50s.

[IGh]

Another observation was offered by "B757 Driver", in message #10:

"...one thing surprises me - 'rolling before pulling' is something ingrained in basic flight training. ... roll level before you pull otherwise you've got a good chance of pulling the aircraft apart...."

Earlier upset mishaps show many of the same conditions described in the AdamAir case. In earlier cases, G-forces recorded seem to increase during the rolling dive, as the IAS increased. Sustained G's go to 2Gs, then 3Gs, civil jet upsets have recorded IAS to about 470KIAS, with the G's spiking to 5.8 Gs (even in non-fatal cases).

There's one element that hasn't been mentioned: DRAG OPTIONS for the victim-pilots, during the high-speed, uncontrolled, rolling-DIVE. In the AdamAir AAR, can you find anything about SPEEDBRAKES??? Were they kept RETRACTED?

This next item will seem very odd to newcomers to these upset investigations: The EXTENSION of the LANDING GEAR was a common element in three historic cases of RECOVERY from UPSET-rolling-DIVE:

From NTSB AAR-94/02/SUM, pg 20, 2nd paragraph: "... The control column was moved aft ... throughout the descent. According to the flight crew, the recovery was initiated soon after the first officer lowered the landing gear...."

[PK-KAR]

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

[punkalouver]

Hi Mr. PK-KAR.

Thanks for your information. Next time you have lunch with an investigator, could you ask him if the NTSC could publish some of the reports for the several accidents that have been in Indonesia over the last several years. Tell him that they are much appreciated by those who are reading them.

Thanks.

[GlueBall]

Irrespective of IRS failure, autopilot disconnect, FMC position anomaly. . . the crew members lacked elementary survival instinct by not immediately hand flying the airplane, using the independently powered stand by attitude indicator as a primary reference to maintain wings level upon autopilot disconnect warning . . . and furthermore, by not doing so after multiple "bank angle, bank angle" warnings.

This scenario is another classic high altitude high speed upset because nobody was flying the airplane when the autopilot kicked off.

In IMC at FL350, at cruise speed, and especially in stormy weather, there is no time for delay to apply total concentration for one pilot at the controls just to maintain wings level and to hold altitude.

Recurring simulator training with impromptu loss of A/P and instrument displays will re enforce the urgency of manual control before the airplane enters an unrecoverable upset. :ooh:

[PK-KAR]

Wouldn’t a THIRD IRU have aided these mishap pilots?
Sure, but I doubt it would on an Adam Air jet. You can have 20 on board IRUs if U can, and still wouldn't help. The main point arising from this accident is that the IRU/S are crucial to your aircraft and needs to be maintained properly. Again it goes back to management commitment to safety. Instead of maintaining the IRUs properly, management decides that it's cheaper to perform "clean contacts and reinstall" as their IRU maintenance, repetitively. It basically got to a stage where if you have 20 IRUs on board, none would have helped. If you go to the management and say you need 2 working ones, they'd say, "look, U got two, one's to back up the other", it's best to just leave the company. Why would 3,10,20 make a difference? They'd just say "look, you got 20 IRUs, only one needs to work. Now stop messing around or I'll make your life difficult."

Irrespective of IRS failure, autopilot disconnect, FMC position anomaly. . . the crew members lacked elementary survival instinct by not immediately hand flying the airplane,
Bingo...
Now the question is, why the lack of the elementary survival instinct?

Pilots in Adam Air have refused to fly unsafe aircraft in the past and management instead of doing something positive about it, decided to give hell to those who refuse. Brown envelopes were sent and those pilots faced legal proceedings for breach of contract and arranged the situation such that those pilots had to settle out of court rather than face bankruptcy. Now, U expect those deciding to stay care about staying alive to the same level as "just a pilot at just another airline" ?

And if they do have that elementary survival instinct, they lacked the proper training.

Recurring simulator training with impromptu loss of A/P and instrument displays will re enforce the urgency of manual control before the airplane enters an unrecoverable upset.
Well, that's pretty obvious. But then, simulator sessions were just "a formality" for Adam Air. One member of the "National Evaluation of Transportation Safety Team" (NETST) appointed by the President last week went on TV that it had previously reported its finding where, a simulator was "available" for 2 hours, and they put 5 pilots into it, of which one was the instructor. The simulator had limited function as it was in a 2 hour break inbetween maintenance, and at the end of it, all 5 was then reported as "completed simulator checks".

Sad isn't it.

Next time you have lunch with an investigator, could you ask him if the NTSC could publish some of the reports for the several accidents that have been in Indonesia over the last several years. Tell him that they are much appreciated by those who are reading them.
Had discussed this in the past, and yes, the first thing I did when I spoke to him was to thank him for the report being published and that all who are interested in safety thanks the NTSC for finally making a lot of these allegations on Adam Air, official, through the report.

It appears from the discussions that those reports are "political hotcakes". The GA200 and KI574 reports being published saw huge opposition from the old guard at the DATC. Only since the head of the DGAC and DATC has been changed can the NTSC release reports by ignoring what the old guard is ranting about. The old "we shouldn't release reports because we do not want to blame anyone or have the report used as an instrument of blame" is no longer valid, those guys are on the loosing side in the NTSC, as the current head belongs to the same group as the heads of DGAC and SATC... reformers.

But, they wouldn't want to rock the boat too much. Relations between members of NTSC and old guard members of DATC has been sour since the GA200 report and now with the KI574 report. Now, the recommendations would, again, show DATC deficiencies, crew training deficiencies and also the airport operators, etc... Plus, of the past accidents, we got Lion Air who's now the political darlings of the aviation industry, and to release reports on Lion Air accidents would be a huge political row within the DGAC, and could result in the reformers being replaced by the old guard. If that happens, we're back to square one again, and none of us want that!

The reports of past accidents will be published when the time is right. They must also be careful on the reaction of the public. The GA200 report was just an eye opener, and now KI574, people want heads to roll. The sad side of it, the media isn't helping, and have spun the reports around to paint airlines (regardless of which accident was mentioned) as evil blood suckers. The reports, and new DGAC policies must be in sync. Just last week, the DGAC revealed that it would punish airlines with "repetitive technical delays", and the passengers must be compensated for such. Within days, we got passengers demanding outrageous compensations for delays at airports, and other silly things, culminating in one occurence where the passengers overcame security and invaded an aircraft demanding that it be flown to their destination because they've faced enough of a delay.

The reform, we'd like it to be quick, but then, if we do it that quickly, we'd have a bigger mess on our hands! We don't want planes crashing, but we don't want pax turning into angry mobs either... one new thing we found this week is that, if we move too slowly, planes will crash, and if too fast, we'd have a riot on our hands. Sad reality.

PK-KAR

[Centaurus]

Recurring simulator training with impromptu loss of A/P and instrument displays will re enforce the urgency of manual control before the airplane enters an unrecoverable upset

So right. Some years ago, while training an experienced captain from Indonesia converting to the 737-200 simulator from F28, he was given an IMC turn towards an NDB. During the turn a failure of the captains ADI was simulated which he did not pick up. Within less than a minute he managed to get into an inverted position before twigging something was amiss. The F/O was silent and quite useless (low time CPL with only 250 hours) and stared disbelievingly at his own displays but said nothing. Now disorientated the captain then switched his attention to the standby ADI which was showing the correct attitude of 130 degrees bank and 20 degrees nose down. Mumbling something about the standby ADI being faulty he reached over and pulled the caging button of the standby ADI. The rest is best left to the imagination.
Chaos resulted until the instructor froze the simulator to de-brief.

[Capvermell]

One thing I don't understand about the management of Adam Air is how they thought this policy of not replacing almost any faulty parts was sustainable in the long run.

Had the airline been on its last legs financially at the time of crisis then the policy of postponing replacement of faulty components as an only short term move might have been understandable, but instead of as this they were a rapidly growing operation taking on more and more aircraft how did they expect to keep all these aircraft operational in the long run if they avoided carrying out almost all essential repairs and component replacement?

Surely it would have been self evident that such a set of policies in a fast growing airline would be bound to lead to serious incident(s) sooner or later and that this would then irretrievably damage the brand and the business that those in charge were so eager to build up? I supppose we have to assume that those in charge were previously in some much simpler line of business where slashing all costs to the bone regardless of merit is a policy that actually worked?

[PK-KAR]

Capvernell,
Well their previous business was import and manufacturing of Chinese motorbikes... they made a quick buck but that business has now AFAIK, closed.

As to the brand image... despite numerous delays, complaints backlog, safety breaches, Adam Air is "still" the official carrier of the national games venue set for later this year... Someone didn't do their homework. Only weeks before the final mishap (Run-off in Batam), Adam Air won "most recognized brand" award. And didn't some organization gave Adam Air the "Merit Award for LCC of the year" ??? That merit award is the funniest, how the PR people managed to tie that up to safety is something beyond belief, but they managed to do it...

One thing the management refused to accept/belief, that in the long run, it's cheaper to do it properly. Maintenance costs would be down, and "brown envelopes" would be less coz U'd use it less often on the authorities and disgruntled pax... And the "monkey budget" for their security (yes one of the largest number of thugs roaming around terminal 1C, is Adam Air's security) would be much less.

PK-KAR

[Capvermell]

Adam Air won "most recognized brand" award. And didn't some organization gave Adam Air the "Merit Award for LCC of the year" ???
Well it certainly is highly recognised just like Helios and SilkAir despite the small sizes of both those airlines. But not all publicity is good publicity.......

... And the "monkey budget" for their security (yes one of the largest number of thugs roaming around terminal 1C, is Adam Air's security) would be much less.

What do the security guys do? Do/did they threaten to attack the families of any pilots who were minded to not take off in an especially dangerous aircraft?

[xetroV]

PK-KAR, thank you very much for your replies!

I think this accident tells us a lot about the general state of affairs at Adam Air, but I also know stories about similar IRS and instrument-related confusions (minus the disastrous subsequent chain of events from this accident) that happened to B737 crews elsewhere. Hence the questions in my first reply.

I don't think the report is deficient, and I fully understand the choices made by the investigators, but (like any report) it raises some additional new questions. I hope people will realize that, regardless of all the safety deficiencies identified at Adam Air specifically, there are still lessons to be learned here for everyone, both inside and outside Indonesia. In my opinion, the insidious nature of partial IRS failures in B737 aircraft can catch even the best trained pilots off-guard. Of course, that doesn't detract anything from the observations regarding lacking failure management and upset recovery during this accident (let alone the maintenance can-of-worms).

[Capvermell]

In my opinion, the insidious nature of partial IRS failures in B737 aircraft can catch even the best trained pilots off-guard. Of course, that doesn't detract anything from the observations regarding lacking failure management and upset recovery during this accident (let alone the maintenance can-of-worms).

I suspect you may be right that in the third world there are a great many other Adam Airs who are neglecting just as much basic maintenance and yet getting away with it (for now). Unfortunately the consequences for the directors of these companies in sanctioning this kind of active wilful negligence are never serious enough. If they were likely to go to jail for 10 years or more (actually in jail that is) for signing off policies that led to such a tragic and fatal outcome then most of them would never think the risk was worth taking.

Coming back to the pilots surely the truth of the matter is that there are many journeymen poorly trained and only moderately competent pilots (especially in the third world) who may lack the intelligence and the training to be able to cope with these highly unusual and unexpected situations out of left field that only the most able pilots will immediately spot and take action to correct. Yet fortunately for most of the mediocre pilots the situation that will really trip them up will never occur on their aircraft in their pilot lifetime and so they may pass through a whole career without their mediocre airmanship skills causing any tragic outcome.

In the case of Adam Air its very doubtful these guys were exceptionally bad pilots (in Indonesian terms) but because of the risks AdamAir was taking with both their and their passengers lives only very good pilots could probably have survived the terrible risks the airline was regularly casting in to their path.

On the scale of pilot errors the error made here was clearly disappointing but nowhere near the same level of basic lack of competence and good sense displayed by the Helios 737 pilots who had minutes to realise their mistake and yet still continued to their doom.

The bottom line is that there are some kinds of insidious equipment failures on each aircraft type that will always present a risk of misdiagnosis by the pilot and a consequent tragic outcome. With this being so the only solution is surely to maintain the aircraft better so that fewer journeymen pilots make such mistakes in the first place. Of course training the pilots yet better too would help but there is only so much good that can do if aircraft maintenance is being criminally neglected.

In the much longer run aircraft can clearly be designed better to prevent most pilot induced crashes so that eventually the main causes of aircraft failure should be only sudden mechanical failure, extreme weather conditions or terrorist action. However that day when pilots are possibly no longer needed is probably still a good 20 to 40 years away.........

[FrequentSLF]

Well it certainly is highly recognised just like Helios and SilkAir despite the small sizes of both those airlines

I would not put Adam Air and Helios on the same level of SilkAir :=

[Capvermell]

I would not put Adam Air and Helios on the same level of SilkAir :=
I suppose you are right. The SilkAir disputed suicide is much more like a directly parallel case to the similarly disputed EgyptAir suicide.

Both are somewhat larger and generally better run airlines that are still in business today. And in each case a rogue suicidal pilot is the main apparent causal factor.

[EMIT]

Having read the reports from the Adam Air at Sulawesi and Garuda at Yogyakarta accidents, I must applaud the frankness with which the causes have been brought forward. If you compare these reports with the reports on the 2 Egyptian accidents (Egypt Air 990 near New York and Flash Air at Sharm), there is no attempt by the national investigators to keep insisting on some mysteryous technical deficiencies.
Of course, the publication of the reports will not improve the situation in Indonesia overnight, but the openness may be a beginning. Compliments to PK-KAR on his excellent postings on this subject.

[zxcui]

Is the priliminary Report KNTT/07.01/01.01 available?

I want to know what had expressed in its paragraph 1.18.3 as mentioned in recommendation 5.1

[PK-KAR]

What do the security guys do? Do/did they threaten to attack the families of any pilots who were minded to not take off in an especially dangerous aircraft?
add cabin crew, flight ops, airport ticket counter staff, journalists, and passengers to that list.

In my opinion, the insidious nature of partial IRS failures in B737 aircraft can catch even the best trained pilots off-guard.
Yes, pilots here are re-checking the manual. We had a coffee get-together the other weekend between enthusiasts, 737 crew, and an investigator, and this was one point raised. The NTSC in the end decided that for the benefit of moving our aviation forward, that they do not put the abovementioned point as a question or recommendation to Boeing. One factor is the fear that someone might try and divert attention from the prevalent systematic deficiencies and purport an argument that Boeing is deficient.

In the case of Adam Air its very doubtful these guys were exceptionally bad pilots (in Indonesian terms)
Well, throw the words "doubt" and "exceptionally" out of that sentence and you get the sentiment of the country's crew pool. We got airlines who refused to accept former Adam pilots for "deficient standards" after they got the good ones, and then the bad ones started applying. Others have decided to accept them on condition of "full retraining".

----------------------
For those who have followed the Adam Air story since my post on "the flying circus nightmare", this accident, and whatever else, I'm putting the following as a "thank you" for those who have followed this, gave me support, or simply, participated with a cool head instead of just slagging of us "Indons" as silly idiots...

*Disclaimer: I have no direct knowledge that the following is >0% accurate, but these are just information I have received.

I had an interesting afternoon with two former Adam Air staff (they personally asked for help in this mess, especially on the career front, but that's a different story). After the usual discussions on the deficiencies in the ops, we went on to deficiencies in other parts of the company. Apparently, it looks like Mr. Adam himself is the victim of his family. Although he is the CEO, the mother calls the shots and she only talks in one language... money. The auntie made a huge sum by collecting ticket money from agents and never gave it to the airline (it is said she burnt the ticket audit coupons to eliminate the evidence), and the brother, well, now I have heard stories from several different sources in Adam Air that he was the one who drove Adam into ruin from day one. According to the information, this is the guy who literally made Adam into an operational nightmare. Apparently, his hand not only screwed up maintenance by deciding to delay maintenance, or forced pilots to fly (and told his mother to force them, or the "monkeys" to do the job, leaving Adam out of the loop), he also overrode recommendations for training, and again, got his mother to override everyone else. God knows how much he made out of the cargo (and since he's in charge of ops, we can guess how much was not reported in the manifest). He seems to have followed his auntie as well in selling tickets to agents, making them pay the money into his account, and never gave the money into Adam Air, and... oh yes, audit coupons were said to have been burnt.

So, the behaviour of certain members of the family really opened the way for corruption, misconduct, and other misdeed to occur within the company. Reservations control was one story that confirmed my suspicion on how Adam flew itself into the ground (and the airplanes followed suit), for one flight, there was an occasion where a 737 had 600 ticketed passengers booked on that flight!!!

The director of safety is now chain smoking continuously outside the HQ everyday, wondering, hopelessly. This was a guy who was stuck between doing good, bad, and the ridiculous, and he staked his career on it and is now paying for it.

Staff haven't been paid their salaries for the past 2 months, due to disputes between the family and the other investor, and no one wants to appoint a liquidator. It looks like the family now is deciding whether to liquidate the company and move on and take whatever is left, or standing their ground and prevent the other investor from taking over Adam Air. The family versus the investor = Two wrongs don't make a right.

The afternoon also revealed how Adam Air managed to keep selling tickets despite the mess, and survive. The way the ticketing offices operate is simply amazing, and they developed many breakthroughs in the airline industry here regarding branding, distribution, and marketing. It is a pity that these brilliant ideas were not supported by a safe and reliable product.

One disturbing fact though. It was revealed to me that my real identity has been known to Adam Air for a long time. I am told that I am fortunate that those in Adam Air who knows my identity hasn't divulged such information to the family. The reason being, that until the very last minute, Adam Air was a continuous battle between the good and the evil. Several wants to get rid of me, several thought it might have been a better idea to pay me for my silence, and several thought that I should have been recruited to join the now lost struggle for the good.

So, enough with the gloom, here's one good bit. The allegations on Adam Air's conduct in 2006 that was put on PPRuNe has been requested to be given to the authorities for further investigation for the NTSC to put recommendations to the industry and the regulator, on how to further address systematic deficiencies in maintenance, incident and serious incident surveillance. Basically, if it does end up as we wish, the recommendations address the questions raised by the National Evaluation Team for Transportation Safety and Security (NETTSS/TimNas EKKT) in early 2007 on, "Why does the DGAC, DCAT and NTSC miss out on so many of the alleged violations and incidents/occurences while certain members of the public (read: not the press) can know and put those information out in a coherent, timely and systematic manner?"

The inability for the DGAC and DCAT and NTSC at the time resulted in the heads of those agencies to be replaced by those who do care about these stuff and want to use all available channels to make the information available to them.

So, thank you guys for all of these so far, now let's hope this ends up the way we want it, that is a better aviation safety where I am. On the other end, I'll have to stay quieter/smarter now. The last thing I want is the "status quo" forces to end up on my doorstep.

PK-KAR

[Capvermell]

PK-KAR I would imagine that you must have had some reason for picking your forum name and therefore also some vague connection with Kartika Airlines that might well allow some in Indonesia to speculate as to your identity? I note that this Kartika B737 has been stored/decommissioned since December 2006.

See

www.airliners.net/search/photo.search?regsearch=PK-KAR&distinct_entry=true (http://www.airliners.net/search/photo.search?regsearch=PK-KAR&distinct_entry=true)

and

www.planesregister.com/aircraft/b737-23796.htm

Your information has certainly been illuminating, although the scale of the corruption revealed in your latest post certainly helps confirm that Adam Air was most definitely a Banana Republic type airline.

No matter how bad things may be over here in the Western World at places like Ryanair and South West Airlines they clearly don't even begin to compare with the old style nepotistic mismanagement and corruption at Adam Air.

[PK-KAR]

Capvermell,
The reason for picking the registration is correct. However,almost no one in the Kartika Air (then, and now) know me. But anyways, they found me through other means, and several "friends" also leaked certain documentation :*:*:*

Anyways, interesting developments. The family has lodged an application for a new airline yesterday. "King and Queen Air" :yuk: This was revealed by the DGAC yesterday.

All I can say to King and Queen Air is... :ugh::ugh::ugh:

PK-KAR

[Capvermell]

Anyways, interesting developments. The family has lodged an application for a new airline yesterday. "King and Queen Air" :yuk: This was revealed by the DGAC yesterday.

I wonder why Kings and Queens would choose an airline with a high probability of never delivering to them their destination.:oh:

Surely if your national regulator is to have any shred of remaining credibility then they must turn down this application.

[Jakarta Jock]

PK-KAR

More power to your elbow. I must say that I find your posts to be first class and help to put matters into an Indonesian context.:D

The background to the financial problems in Adam Air as described do have a "ring of truth" and it would be funny if it were not so serious.

That said take care and keep your head down!!!!!!!!!

[mary_hinge]

http://www.rati.com/frameset/frameset_f.asp?target=../news/news.asp

Indonesia cancels Adam Air's AOCLeithen Francis, Singapore (23Jun08, 09:54 GMT, 244 words)
Indonesia has cancelled the air operator’s certificate (AOC) of grounded Indonesian carrier Adam Air, putting an end to an airline that was involved in Indonesia’s most fatal crash in the last couple of years.

[ronnieight]

Adam Air Flight 574 voice recording:

RapidShare: Easy Filehosting (http://rapidshare.com/files/133783829/Rekaman_Adam_Air.mp3.html)

Or here:

YouTube - Rekaman Adam Air Sebelum jatuh (http://www.youtube.com/watch?v=0dC5fIsvDNU)

or here:

http://tengkorak.meektube.com/for/ccpb/only/Rekaman_Adam_Air.mp3

[PK-KAR]

I've received a few queries on this recording over the past 24hrs, and some from PPRuNe members...

I saw the link at a local forum yesterday, and a few colleagues took it to bits, and we seem to conclude that this recording is real, and most likely to come from the cockpit area mic... the gaps between the parts of the conversation matches the FDR and whatever transcript was in the accident report.

Today I ran into a couple of ex Adam Air pilots, and they wanted to hear this recording. They did say it was the right voices for the Capt. and F/O. The sadness in their faces when hearing this was... beyond words, especially the guy who flew the jet a few days beforehand... with the same problem... He was in the process of quitting when the crash happened.

The media here have put out a simulation of the accident based on this recording and the FDR data in the accident report... dunno how accurate their potrayal is...

PK-KAR

[atakacs]

Is there an english transcript somewhere ?

[punkalouver]

Thanks PK-KAR. Now that things have settled down for a bit, is there much chance of more past accident reports being released. I found the last two quite well written.

[pacplyer]

Nothing but a hypothetical story follows:

Talk about the twilight zone......

Maybe once in your whole career, you're going to have to take the airplane away from a Captain who can't direct task-management correctly, or has quit flying the airplane for some reason.

This is the oldest cockpit story in the world. One guy MUST fly while the other diagnoses a problem. You can't have both of them troubleshooting. And if that guy can't keep the wings level, you MUST grab the controls, get it out of the [over] bank it's in, and recover. "Captain Captain Captain" is not assertive enough. State: "Captain I have the Aircraft," and do what you gotta do. But you better be right. Yes, you are probably going to loose your job. But at least you will be alive.

I had to do it once as a Flight Engineer and I will never forget it. Both "front enders" were continuing a bad GCA approach where foreign commuications became very uncertain. A different voice broke in and asked if we were going around (atc supervisor?) The GPWS went off and both guys ignored it, Captain pushing the G/S O/R button. I couldn't believe that both pilots weren't getting a read that this new controller was telling us something was wrong. Then he said: "you are Way North of Centerline and Way below Glidepath, are you going around?). They kept the sink rate going to minimums (that was the reason proffered later for not going around: he wasn't at minimums yet.) I pushed the power up from the back all the way to the stops and said to the pilot flying "Go Around, it's no good, Go Around, I'm giving you max power." I was sure I was fired. The F/O was shocked exclaiming "you don't do that, you just don't do that!" But the G/A was commenced. Then we for a second, we thought we saw the rooftops going by the windshield way too close, so I was later congratulated in the bar. But if it had been night, I'd probably be homeless right now....

I once was heavily criticized by a monday morning check captain for returning to base since the co-pilot was neither capable that day of flying or of any systems knowledge whatsoever. There was no way I was going to fool around with this serious mechanical problem while nobody flew the machine.

Maintenance was very unhappy with me that day, but this problem had been going on for weeks on this airframe.

The bottom line is that the PIC must be able to reject a broken airplane if he's been riding around on autopilot all month and is not up to a partial panel flying emergency.

The above is all just my opinion only.

[PK-KAR]

This is the oldest cockpit story in the world. One guy MUST fly while the other diagnoses a problem. You can't have both of them troubleshooting. And if that guy can't keep the wings level, you MUST grab the controls, get it out of the left bank it's in, and recover. "Captain Captain Captain" is not assertive enough. State: "Captain I have the Aircraft," and do what you gotta do. But you better be right. Yes, you are probably going to loose your job. But at least you will be alive.

PK-KKW Irony #1:
F/O's voice stress level rising consistently while captain's seems to be on a roller coaster. Captain was PF.

Irony #2:
After bank angle alert, F/O put a left roll input as the plane was banking right... Captain said "Don't turn it!"

Irony #3:
F/O former fighter pilot, Captain had no upset recovery training. Captain was PF...

Irony #4:
F/O former fighter pilot, normally a hard head on CRM, but over recent years, former fighter pilots have been "humbled" in many cases, and as this case shows, resulting in lack of assertiveness. RIP.

And how many accidents/incidents have happened in Indonesia involving an F/O knowing a disaster was going to happen and did nothing/not do enough?

When ironies happen, swiss cheese holes line up, and the flag gets ironed out in case we need a half mast...

I found the last two quite well written.
Don't hope too much the previous ones are gonna be re-written or released for public.

Is there an english transcript somewhere ?
Parts are in the final report (link to it is in this topic somewhere)

But here's a draft or two based on the recording (not written by me, I have not found the time to check and edit much)...

1.07 FO “not sure” DME is working fine (on FMS display)
1.10 Capt confirmed …..”yes that was what is wrong with it”
1.12 FO Try to recognize MKS – VOR
1.32 FO Says.. if mean while got the wind direction indicates back in normal
1.53 Capt your DME is totally different with this FMS picture
1.56 Capt Expressive …If DME Indicator (dedicated) was not in agreed with the FMS Displays...
2.00 FO Says….(jokes) this aircraft become/like a wooden vessel.
2.05 FO Says…”oke we must trust with this anyway”,…
2.08 Capt (little laugh)….”yes it is,..”
2.13 Capt “it has gone too far”…..
2.15 Both pilot beginning not sure with the cross track angle become bigger and bigger
2.21 Capt Says,…”Again it was wrong with the heading,…”
2.25 Both pilot try to confirmed/established a/c position,…
While Capt says…(ask FO),.. “established report position to ATC on Radial something
……124 DME”…. (means from MKS)
2.45 Capt Says,…”something wrong with EFIS”
2.47 FO Says,….” No this FMS”
2.50 Capt Says,…”FMS is confusing themselves”
3.13 Capt Says,…“I will try IRS mode change over to ATT” (attitude reference)
<--- My edit: A/P disconnect sound
3.30 FO (open the QRH book),….”it will comes to Fault ,…?” (IRS Fault Procedure on QRH)
3.36 FO “…IRS Mode Selector,..?
3.38 Capt “…Attitude”…..
3.40 FO “…which is ‘Left’…..?
3.53 Capt “…initial called for Altitude,…..?”
3.54 FO “…enter the Heading,..?”
3.55 FO Says,…..”What it was Heading now,..Capt,..?”
3.58 Capt “…Zero,……..zero seven nine ,…ya,..”
4.00 Both pilot confirmed/agreed with the current heading 079
4.20 “Bank Angle”,……!!!........
4.22 Capt “…switch the NAV again”………..(back ground sound….still “Bank Angle”,……!)
4.23 Capt (strong Voice),…. “switch the NAV again”,…. “switch the NAV again”…!!!”
4.25 “Nnooottt”,………(Altitude ‘sign’ Warning “sound”/reminder for 1000 feet to go)
4.27 “Bank Angle”,……!!!........
4.28 Capt “…switch the NAV again”
4.29 FO (strong Voice),….”NAV,…!!!”……oke capt,…
4.33 Capt (Shout,..),…..”Don’t Turning it!!!”….
4.35 Capt (Shout,..),…..”We must keep in these Heading,..!!!”
4.39 FO (Shout,..),.”Captain,…Captain….Captain,..!!!” (ask for command control ‘side’ for MCP/FD???)
4.42 “Clack,…Clack,..clack,….!!....(“Clacker” – Over speed warning “sound”/indicates Exceeding over speed limit)
4.45 FO “….Ach,..Capt,…Capt,…!!
4.46 Capt “…Yak,..yak,…!!
4.53 Allahuakbar”…!!!.(All Mighty Allah),…..
4.55 “Allahuakbar”…!!!
4.66 “Allahuakbar”…!!!
4.57 “Allahuakbar”…!!!
4.58 “Allahuakbar”…!!!
4.59 “Allahuakbar”…!!!
5.02 strong sound noise of airframe stressed due to over speed exceeding beyond limits
5.04 strong sound noise of airframe stressed due to over speed exceeding beyond limits
5.07 “What is this,..?!!!,…..what is this,…?!!!
5.13 sound something hard impact (inside cockpit)
5.14 “Aaaaaauuuuw,…. “Allahuakbar”…!!!
5.20 “Allahuakbar”…!!!
5.27 “Allahuakbar”…!!!
5.28 “Allahuakbar”…!!!
5.33 “Allaaaaaahhhhhuuuuakbaaaaaaaar”…!!!
5.36 ………………..silent…………………….(impact point)

As a result of this recording appearing on the internet, and the NTSC has not accepted nor deny the validity of this recording (which everyone now assumes, it is not a fake), the families are now going to commence legal proceedings against Adam Air, whatever is left of Adam Air, shareholders and former shareholders of the airline, either/both in civil and/or criminal law.

The mother of one of the F/As on board has also said, she can now be at peace knowing what happened on the last few moments, thanks to recordings...

PK-KAR

[ronnieight]

The mother of one of the F/As on board has also said, she can now be at peace knowing what happened on the last few moments, thanks to recordings...
Glad to know the recording provides some reliefs to the family of the victims. Interestingly, this recording was found by a sibling of one of the victims after a long rigorous search and somewhat the recording ended up on the internet yesterday and it's circulating fast.

[PK-KAR]

Ronnie8,
Where did you hear that?
Btw, where was the first source on the internet? the earliest I got is 31Jul on 4shared... but it's been running around for a bit I am told...

-KAR

[India Four Two]

From the report:
When ATT (Attitude) was selected in the IRS Mode Selector Unit, it resulted in
the autopilot disengaging. The effect on the copilot’s EADI of switching from
NAV to ATT was that the following displays were lost:
· Roll indication
· Horizon scale
· Pitch scale
· Sky/ground shading.
Flight path angle, Acceleration, Pitch Limit display and Traffic Alert and
Collision Avoidance System (TCAS), Resolution Advisory (RA) commands
are also removed when ATT is selected. Can someone explain to me why the attitude information disappears when you switch from NAV to ATT?

[GlueBall]

Ironically, the CVR confirms the written report's revelation about the crew's utter incompetence of basic airmanship; namely that of maintaining wings level attitude by reference to the independently powered SAI [Standby Attitude Indicator] after the synthetic voice generated warning: "Bank Angle, Bank Angle."

[petermcleland]

Well, having read that report, I have to say how grateful I am to have flown my years in command with a three pilot crew. :)

[punkalouver]

Not on the 737-400 myself.

I notice that on the second last page(83), it says that " the copilot did not inform the PIC when he selected attitude on the right MSU, even though the PIC instructed him to select the left one".

Could this have led to a situation the captain thought that an ADI indication was accurate when in fact it was not and therefore confusion over why the bank angle call was being made? Or is an obvious message annunciated on an ADI when attitude is selected?

[pacplyer]

punkalouver,

I only flew the classic 737 briefly, so my display and nav switching knowledge is lacking on this model. Also I'll use ADI instead of glass names.

Loss of Nav:
Reads kinda like without a warn/fault light on either of the IRU's the F/O was confused about which one deserved to be switched to ATT. This freaked the Captain because he wanted heading info punched into his IRU from the one the F/O just killed!

But yelling to go back to NAV was a real systems knowledge failure on the part of the Captain. ATT is a one-way-ticket, as others have pointed out; once you go there the horse has galloped out of the barn and it can only give you reduced presentation attitude info for the rest of the flight.

Some great earlier posts in this thread. Looks like the CAM recording has disappeared off those links on the net, so there must be some damage control going on? :confused:

Looks like these guys were handed a very unenviable situation. One or two bad IRU's (since it sounds like all this airline did was swop them when there was a write up) possible improper differences training (all-too common today,) possible inadequate abnormal checklist distribution.

Loss of A/P: (I'm assuming the A/P was lost as a result of the #2 MSU selected to ATT by the F/O)
But assuming a functioning SAI, (can we on this ship, PK?) both guys, if they're any good, should be doing a cross scan at all three attitude displays: Cpts, F/O's and the SAI before platform alteration occurs. #2MSU is switched to ATT:A/P lets go. A/P horn is cancelled. When the bank angle warning goes off, your primary horizon reference can no longer be trusted. When the altitude alerter tone goes of at ~250' off assigned, you're probably already doing unintended steep turns and losing altitude with increased load factors, who knows. You've had two clues that you're losing it; it's time to abandon the Captain's ADI and go back to the SAI (the F/O's ADI is not usable for 30 secs, right?).

Hard core instrument pilots flying junk call this: maintaining critical triangles of agreement.

But, because of good automated instrument comparator systems today, this old stick and rudder skill (cross-cockpit scan) is sorely lacking in todays air line pilot. Not all the guys I flew with in later years were even capable of flying without a flight director, let alone hand flying raw data across the cockpit at altitude for very long. If you don't keep current hand flying you will pay the price one night when "Outto" decides he's had enough of this flakey maintenance at this place and drops out when ATT is selected.

Ideally, before you start changing anything, you should have an idea which of the three horizon displays is presenting good info. You should then verify that your chosen primary horizon ref (for example: the Captain's ADI) is selected to it's normal display source: (e.g: The #1 IRU?) Instrument switching (which they never even got to) can be tricky, and before you get to restoring displays or even altering platforms as they did, the handing pilot has got to have faith that his interim source of wings level info is working for him.

But you should realize that failures can be progressive, and that you have to keep up the critical triangles of agreement going. Compare both remaining horizons with heading raw data change.

The no checklist way:
Normally, you just vote the odd horizon out. In this case, knowing the ship history and the airline, that's not good enough. The Pilot Flying (Capt) should be verifying partial panel behavior. He should instruct the co-pilot to get a flashlight out and dig out the wiskey compass taking readings of it for a minute in S&L and make sure his selected attitude reference is not changing heading on him (sounds like it did.)

Again, today's modern airline pilot almost never has to do this. 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.

But the colleague that you criticize for hand flying all the time (John Wayne) would have made it to the bar alive maybe.

The above are all just my contrarian opinions only.

[punkalouver]

I am wondering if the captain was thinking that the #2 ADI was working because he had asked for #1 to be switched to ATT(#2 was switched to ATT instead by the copilot, for whatever reason quite possibly without the captain's knowledge).

Therefore in the captain's mind, when the 'bank angle' callout was made, he thought it was a false warning based on what he was now assuming to be the now unreliable #1 ADI(which was in fact reliable) and then didn't use or took too much time to use the standby horizon for confirmation until it was too late.

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.

[CSilvera]

Well gee then I guess you've just insulted Allah and every Muslim pilot! Didn't you see how this worked with Egyptair 990? Lawsuit/banning/stoning to follow.

[punkalouver]

The solutions for everything in these societies.

[FrequentSLF]

Would the airbus aplha protection have prevented/mitigated such occurence?
Thanks

[A37575]

Sounds to me like: This flight was beyond the abilities of most auto-pilot dependent line pilots.


Never a truer word except delete "most" and add "every"...

[pacplyer]

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. :suspect:

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! :uhoh:

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. :ugh:

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.

[PK-KAR]

But assuming a functioning SAI
Well, the NTSC report did assume the same, details over there... 1.18 I think... can't remember...

Not all the guys I flew with in later years were even capable of flying without a flight director
A very sad reality. I guess that'll be more true when we get flooded with MPL'ers...

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.
Again, the sad thing is, if they just continued and tried to obtain every raw data updates they could, they would have been alive perhaps? A jumpy edgy "this box is screwed" thinking process due to lack of training lined up the swiss cheese that day.

Sounds to me like: This flight was beyond the abilities of most auto-pilot dependent line pilots.
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.

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.
Errr... Going "AllahuAkbar" is a polite way of saying "Oh sh1t! God help me! *yes I'm a Muslim*, and you only need to change the intonation to signify your desperation... But that does not mean this prevents them from taking the necessary recovery actions. THE PROBLEM HERE IS... THEY RECEIVED NO TRAINING ON UPSET RECOVERY!!!! The only guy with the experience to do so in the flight deck was told off by the Captain "Don't turn it" and obeyed in "good CRM spirit because he's a former fighter pilot and he needs to be a good CRM boy otherwise he might be in trouble"...

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?
Nope, but the 60deg "hard limit" and overspeed pitch command protection from the FBW MIGHT!!! *not sure how fiddling with the GPIRS on a Bus affects those protections*

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.)
BINGO! u got it.

The only thing possible at this point is full F/O mutiny and flight off the SAI.
The thing is, the "rebuke" also meant the 5 left aileron inputted by the F/O was given a 7 deg right aileron by the Capt... putting it back EXACTLY where it was (good handling skills under spatial disorientation... recipe for disaster).

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.
Adam classics pilots wouldn't fly if the aircraft has a bad SAI and IRS... it's gotta be one or the other... their own unpublished self preservation rule...

PK-KAR

[pacplyer]

The following is all fiction and opinion just for entertainment purposes only:

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.


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. :suspect:

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. :yuk:

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!) :ooh:

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. :ok:

[CaptainSandL]

From The Jakarta Post, 4 Aug 08 (http://old.thejakartapost.com/detailnational.asp?fileid=20080804.H02&irec=1)


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 (http://www.dephub.go.id/knkt) 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.

[pacplyer]

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? :confused:

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

[lomapaseo]

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?

[pacplyer]

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.

[punkalouver]

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.

[flash8]

You obviously haven't flown with many "non Western" Pilots. I'm sorry thats a highly contentious remark if I've ever heard one.

[lomapaseo]

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

Glad to see that this thread is moving in a positive direction.

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.

[FrequentSLF]

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.

An European was the commander of the CI MD11 (B-150) in HKG in 1999...

[Centaurus]

https://en.wikipedia.org/wiki/Adam_Air_Flight_574

Worth re-reading and a good reason for unusual attitude training during type rating training.

[Stan Shunpike]

Is 16 years a record for thread resurrection? :8

[KRviator]

Is 16 years a record for thread resurrection? :8Could well be, but nonetheless when @Centaurus speaks, I listen. He's got a lifetime of experience that I could never hope to achieve. And some cracker yarns to go with it.

[VH-MLE]

I kept a copy of some of the flight data for this accident which shows an astronomical rate of descent...