'Adam Air Case\r'

'MINISTRY OF f are National Transportation guard military commission Gedung Karya Lt. 7 Departemen Perhubungan Jl. Medan Merdeka Barat No. 8 JKT 10110 INDONESIA forebode : (6221) 3517606, (6221) 3811308 Ext. 1497 TOKA : 19811 Fax : (6221) 3847601 Website : www. dephub. go. id/knkt Email : [email protected] go. id open RELEASE OF FINAL REPORT †PK-KKW †FL DHI 574 like a shot the National Transportation Safety direction is releasing its final publish into the stroking involving AdamAir PK-KKW Flight DHI 574 on 1 January 2007.\r\nWe bid our prayers and condolences to the families of the passengers and crew. The NTSC has reviewed the comments on the draft final report from the related parties in accordance with ICAO lengthiness 13. Now I am equal to report to you that as of today, squiffy and reserve safety put to death had been interpreted during the track of the investigation by the DGCA and AdamAir and Angkasa Pura I, on ogdoad of the eleven recommendati ons in the report. The last collar recommendations are only being issued today.\r\nThe Boeing 737, registered PK-KKW, foregone from Djuanda Airport, Surabaya at 05:59 Coordinated common Time (UTC) under the instrument rush rules (IFR), with an estimated time of arrival (ETA) at surface-to-air missile Ratulangi Airport, Manado of 08:14. in that location were 102 people on room; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants. The aircraft disappeared from radio breakion and ranging while cruising at 35,000 feet. Following an ample land, air, and sea search, wreckage was found in the piddle and on the shore along the gliding near Pare-Pare, Sulawesi 9 days subsequentlywards the aircraft disappeared.\r\nLocator beacon signals from the pip recorders were perceive on 21 January 2007 and their positions logged. The search was suspend when it was determined that the wreckage was located in the marine at a depth of close 2,000 me ters, requiring specialized call upy equipment not accessible in the Region. The salvage operation to recover the dodging recorders commenced on 24 lofty 2007 and the Digital Flight Data vertical flute and Cockpit Voice Recorder were recovered on 27 and 28 August 2007 respectively.\r\nThe CVR revealed that some(prenominal) pilots were concerned about navigation problems and by and by became engrossed with trouble shooting inertial savoir-faire System (IRS) anomalies for at least the last 13 minutes of the flight, with marginal regard to other flight requirements. This acknowledge identification and attempts at corrective actions. The DFDR depth psychology showed that the aircraft was in cruise at FL 350 with the autopilot engaged. The autopilot was holding 5 degrees left aileron wheel in order to entertain go-level.\r\nFollowing the crew’s pickaxe of the number-2 ( properly) IRS Mode Selector Unit to ATT (Attitude) mode, the autopilot disengaged. The misrepre sent wheel (aileron) then bear on and the aircraft began a slow roll to the justifiedly. The aural alert, BANK ANGLE, sounded as the aircraft passed 35 degrees right rely. The DFDR information showed that even aft(prenominal) the aircraft had reached a bank angle of 100 degrees, with the careen attitude approaching 60 degrees aircraft cuddle down, the pilot did not roll the aircraft wings level before attempting pitch retrieval in accordance with standard procedures. The aircraft reached 3. g, as the speed reached Mach 0. 926 during sustained noseup elevator control input while still in a right bank. The recorded airspeed exceeded Vdive (400 kcas), and reached a maximum of approximately 490 kcas just previous to the end of recording. Flight recorder data indicated that a significant structural disaster occurred when the aircraft was at a speed of Mach 0. 926 and the flight load suddenly and rapidly converse from 3. 5g to negative 2. 8 g. This g pull up and airspeed are beyo nd the design limitations of the aircraft. The aircraft was in a critically uncontrollable res publica at that time.\r\nThere was no march that the pilots were appropriately controlling the aircraft, even after the BANK ANGLE alert sounded as the aircraft’s roll exceeded 35 degrees right bank. This accident resulted from a combination of factors including the unsuccessful person of the pilots to adequately monitor the flight instruments, curiously during the final 2 minutes of the flight. immersion with a malfunction of the Inertial abduce System (IRS) diverted both pilots’ assist from the flight instruments and allowed the increasing descent and bank angle to go unnoticed.\r\nThe pilots did not detect and appropriately arrest the descent presently enough to prevent loss of control. skilful log (pilot reports) and maintenance records showed that between October and celestial latitude 2006, there were 154 recurring dents, directly and indirectly related to the aircraft’s Inertial Reference System (IRS), mostly the left (number-1) system. There was no evidence that AdamAir included segment reliability in their Reliability comprise Program (RCP) to ensure the effectiveness of the airworthiness of the aircraft components for the elapse at the time of the accident.\r\nDuring the investigation the NTSC issued a number of recommendations to the Directorate General well-bred Aviation (DGCA) and AdamAir relating to IRS maintenance and didactics of flight crews in IRS and aircraft reach recovery. I am pleased to announce the go alonging strong positive safety actions. AdamAir rede the NTSC and DGCA that it has interpreted safety action to address the IRS defect troubleshooting procedures and maintenance oversight supervision.\r\nIt issued Engineering Orders with operating instructions and procedures for the evaluation and rectification of repetitive IRS problems, and from November 2007 has had grand liaison with the IRU manufactur er. The safety action taken to date by AdamAir includes ground initiate and aircraft simulator training for pilots to ensure proficiency in upset recovery from 14 January 2008. The DGCA advised the NTSC that on 23 November 2007 it issued a Safety Circular, to all airline operators, requiring specific action to address deficiencies noted by the NTSC, in special(prenominal) the IRS maintenance and pilot training deficiencies.\r\nThe DGCA requires operators to conduct continuing analysis and watchfulness of repetitive defects and ensure immediate follow up corrective action. The DGCA has also assured operators that it is actively monitoring aircraft defects, in particular repetitive defects, and when the on-condition basis of maintenance is deemed to be insufficient to eliminate repetitive defects, DGCA will require component replacement on a hard-time basis.\r\nOn 10 attest 2008, the DGCA informed the NTSC that in addition to requiring upset recovery training from 8 January 2008, the DGCA requires operators to include spatial disorientation and its effects in their syllabus of initial and recurrency training. The DGCA plans to ensure, through rule flying operations inspections, that operators and flying schools are complying with this requirement. The report will be in stock(predicate) on the NTSC web site after the media conference: http://www. dephub. go. id/knkt/ntsc_aviation/aaic. htm JAKARTA, 25 MARCH 2008\r\n'