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Status:Definitief
Datum:maandag 1 januari 2007
Tijd:ca 14:59
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different
Boeing 737-4Q8
Luchtvaartmaatschappij:AdamAir
Registratie: PK-KKW
Constructienummer: 24070/1665
Bouwjaar: 1989-01-11 (18 years)
Aantal vlieguren:45371
Aantal vluchten:26725
Motoren: 2 CFMI CFM56-3C1
Bemanning:slachtoffers: 6 / inzittenden: 6
Passagiers:slachtoffers: 96 / inzittenden: 96
Totaal:slachtoffers: 102 / inzittenden: 102
Schade: Vernield
Gevolgen: Written off (damaged beyond repair)
Plaats:85 km (53.1 mijl) W van Pambauang (   Indonesië)
Fase: Kruisvlucht (ENR)
Soort vlucht:Binnenlandse lijnvlucht
Vliegveld van vertrek:Surabaya-Juanda Airport (SUB/WARR), Indonesië
Vliegveld van aankomst:Manado-Sam Ratulangi Airport (MDC/WAMM), Indonesië
Vluchtnummer: 574
Beschrijving:
The Adamair flight went missing during a domestic flight to Manado. Last contact was at 14:07 when the flight was enroute at FL350. Initial reports indicate that the flight changed course twice as a result of severe (130 km/h) crosswind. The airplane crashed into the sea. On January 11 part of a jetliner's tail, food trays and other debris was pulled from the sea. On January 25 a U.S. navy ship detected signals coming from the flight recorder.
The FDR was recovered from a depth of on 2000 m August 27. The CVR was recovered on August 28 from a depth of 1900 m.
Investigators found that, during the flight from Surabaya to Manado, the Inertial Reference System (IRS) malfunctioned. Both pilots became engrossed with trouble shooting the IRS anomalies for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. The pilots selected Attitude in the IRS, which disengaged the autopilot. After the autopilot disengaged and the aircraft rolled right and exceeded 35 degrees right bank, the pilots appeared to have become spatially disoriented. Control was lost and the airplane broke up and crashed into the sea.

Probable Cause:

CAUSES:
1) Flight crew coordination was less than effective. The PIC did not manage the task sharing; crew resource management practices were not followed.
2) The crew focused their attention on trouble shooting the Inertial Reference System (IRS) failure and neither pilot was flying the aircraft.
3) After the autopilot disengaged and the aircraft exceeded 30 degrees right bank, the pilots appeared to have become spatially disoriented.
4) The AdamAir syllabus of pilot training did not cover complete or partial IRS failure.
5) The pilots had not received training in aircraft upset recovery, including spatial disorientation.

OTHER CAUSAL FACTORS:
1) At the time of the accident, AdamAir had not resolved the airworthiness problems with the IRS that had been reoccurring on their Boeing 737 fleet for more than 3 months.
2) The AdamAir maintenance engineering supervision and oversight was not effective and did not ensure that repetitive defects were rectified.

Accident investigation:
cover
Investigating agency: NTSC Indonesia
Status: Investigation completed
Duration: 1 year and 3 months
Accident number: KNKT/07.01/08.01.36
Download report: Final report
Language: English

Bronnen:
» SKYbrary 
» Confusion over missing Indonesian airplane (Int. Herald Tribune, January 2, 2007)


Veiligheidsmaatregelen

NTSC issued 27 Safety Recommendations

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Foto's

photo of Boeing-737-4Q8-PK-KKW
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: PK-KKW
photo of Boeing-737-4Q8-YU-AOO
accident date: 01-01-2007
type: Boeing 737-4Q8
registration: YU-AOO
 

Aircraft history
date registration operator remarks
11 JAN 1989 G-BNNL Dan-Air Services
07 NOV 1992 G-BNNL British Airways airline merged
19 MAR 1995 G-BNNL GB Airways
06 APR 2001 G-BNNL National Jet Italia leased
26 FEB 2002 N112TR WFBN
04 MAR 2002 EI-CXH Air One leased
20 DEC 2002 YU-AOO JAT leased
13 MAR 2003 N240LF ILFC returned
27 MAR 2003 YU-AOO JAT Airways leased
17 DEC 2005 PK-KKW Adam Air leased

Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen Surabaya-Juanda Airport en Manado-Sam Ratulangi Airport bedraagt 1666 km (1041 miles).
Accident location: Exact; as reported in the official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
languages: languages

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Boeing 737-400

  • 486 built
  • 10e ongeval
  • 6e dodelijk ongeval
  • The zwaarste ongeval
» safety profile

 Indonesië
  • 6e zwaarste ongeval (toen het plaatsvond)
  • 9e zwaarste ongeval (op dit moment)
» safety profile

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