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1、 KNKT/07.01/08.01.36 NATIONAL TRANSPORTATION SAFETY COMMITTEE MINISTRY OF TRANSPORTATION REPUBLIC OF INDONESIA 2008 BOEING 7374Q8PKKKWMAKASSAR STRAIT, SULAWESIREPUBLIC OF INDONESIA1 JANUARY 2007N NA AT TI IO ON NA AL L T TR RA AN NS SP PO OR RT TA AT TI IO ON N S SA AF FE ET TY Y C CO OMMMMI IT TT T
2、E EE E Aircraft Accident Investigation Report ISBN: 9789791695817 When the NTSC makes recommendations as a result of its investigations or research, safety is its primary consideration. However, the NTSC fully recognizes that the implementation of recommendations arising from its investigations will
3、 in some cases incur a cost to the industry. Readers should note that the information in NTSC reports and recommendations is provided to promote aviation safety. In no case is it intended to imply blame or liability. This report was produced by the National Transportation Safety Committee (NTSC), Ka
4、rya Building 7th Floor Ministry of Transportation, Jalan Medan Merdeka Barat No. 8 JKT 10110, Indonesia. The report is based upon the investigation carried out by the NTSC in accordance with Annex 13 to the Convention on International Civil Aviation, Indonesian Law (UU No.15/1992), and Government Re
5、gulation (PP No. 3/2001). Readers are advised that the NTSC investigates for the sole purpose of enhancing aviation safety. Consequently, NTSC reports are confined to matters of safety significance and may be misleading if used for any other purpose. As NTSC believes that safety information is of gr
6、eatest value if it is passed on for the use of others, readers are encouraged to copy or reprint for further distribution, acknowledging NTSC as the source. i TABLE OF CONTENTS TABLE OF CONTENTS.i TABLE OF FIGURES.iv LIST OF APPENDIXES.v LIST OF FIGURES APPENDIX A.vi GLOSSARY OF ABBREVIATIONS.vii SY
7、NOPSIS .1 1. FACTUAL INFORMATION.5 1.1 History of the Flight.5 1.2 Injuries to Persons.9 1.3 Damage to aircraft.9 1.4 Other damage.9 1.5 Personnel information .9 1.5.1 Cockpit crew.9 1.5.2 Pilot in command.9 1.5.3 Copilot.11 1.6 Aircraft Information.13 1.6.1 Aircraft Data.13 1.6.2 Engine Data .13 1.
8、6.3 Underwater Locator Beacon.14 1.6.4 Weight and Balance.14 1.6.5 Maintenance.14 1.7 Meteorological Information.15 1.8 Aids to Navigation.19 1.9 Communications.19 1.10 Aerodrome Information .19 1.11 Flight Recorders.19 1.11.1 Digital Flight Data Recorder.19 1.11.2 Cockpit Voice Recorder .24 1.11.3
9、Notable facts from the CVR.25 1.12 Wreckage and impact information.29 1.13 Medical and Pathological Information.29 1.14 Fire.29 1.15 Search and survival aspects.29 ii 1.15.1 Search.29 1.15.2 Survival.33 1.16 Test and Research.34 1.17 Organizational and Management Information.35 1.17.1 Adam SkyConnec
10、tion Airlines (AdamAir).35 1.17.2 Directorate General Civil Aviation (DGCA) surveillance of AdamAir flight operations and airworthiness.36 1.18 Additional Information.37 1.18.1 Standby Attitude Indicator Erection to false vertical.37 1.18.2 IRS Transfer Switch, Figure 11, item 1 .38 1.18.3 Electroni
11、c Flight Instrument (EFI) Transfer Switch, Figure 11, Item 2 .39 1.18.4 Mode Selector Unit (MSU), Figure 11, item 3 .39 1.18.5 Autopilot Disengage.40 1.18.6 Navigation System Description.41 1.18.7 Inertial System.41 1.18.8 IRS Alignment.42 1.18.9 Loss of Alignment.42 1.18.10 Navigation System Assess
12、ment IRUs.42 1.18.11 Flight Management System.43 1.18.12 Aircraft on Ground.43 1.18.13 Aircraft - Airborne .44 1.18.14 Pilots Flight Track Information.45 1.18.15 General information on Makassar Advanced Air Traffic Services (MAATS) Air traffic control related issues.46 1.18.16 Radar .46 1.18.17 Huma
13、n Factors .48 2. ANALYSIS.49 3. CONCLUSIONS.55 3.1 Findings.55 3.1.1 Operations related issues.55 3.1.2 Maintenance engineering related issues; AdamAir.56 3.1.3 Maintenance engineering related issues; Directorate General Civil Aviation.57 3.1.4 Other findings.57 3.2 Causes.57 3.2.1 Other Causal Fact
14、ors.58 iii 4. SAFETY ACTION.59 4.1 Directorate General Civil Aviation .59 4.2 AdamAir maintenance.60 4.3 AdamAir operations.60 4.4 Angkasa Pura I .62 5. SAFETY RECOMMENDATIONS .65 5.1 Recommendation to Directorate General Civil Aviation (DGCA).65 5.2 Recommendation to Directorate General Civil Aviat
15、ion (DGCA).65 5.3 Recommendation to Directorate General Civil Aviation (DGCA).66 5.4 Recommendation to the Directorate General Civil Aviation (DGCA) and Adam SkyConnection Airline.66 5.5 Recommendation to Directorate General Civil Aviation (DGCA).67 5.6 Recommendation to Adam Air and other Indonesia
16、n airlines operating Boeing 737 aircraft .67 5.7 Recommendation to Directorate General Civil Aviation (DGCA).68 5.8 Recommendation to Adam SkyConnection Airline.68 5.9 Recommendation to Ministry of Transportation of the Republic of Indonesia. .68 5.10 Recommendation to Angkasa Pura I.68 5.11 Recomme
17、ndation to AdamAir.69 6. APPENDICES .71 iv TABLE OF FIGURES Figure 1 : PK-KKW, AdamAir Boeing 737-4Q8 at Jakarta on 3 June 2006 .5 Figure 2: Route orientation chart showing route W32 and waypoints and reporting points .7 Figure 3: Convective activity weather map of 07:00 UTC showing location of PK-K
18、KW near severe weather cell at 06:54 UTC .16 Figure 4: Satellite image of clouds over Indonesia 1 January 2007 at 06:00 UTC.17 Figure 5: Satellite image of clouds over Indonesia 1 January 2007 at 12:00 UTC.18 Figure 6: Fixed time forecast chart for ICAO area E Significant Weather from FL250 to FL 63
19、0. Valid 1200 UTC on 1 January 2007 showing forecast isolated embedded cumulonimbus cloud in the area of the flight.18 Figure 7: Calculated rate of descent .23 Figure 8: DFDR plot showing last 130 seconds of recorded data.28 Figure 9: Diagram of typical underwater detection equipment.30 Figure 10: C
20、olor sonar schematic search diagram.30 Figure 11: The multi-beam scanning.31 Figure 12: Outboard section of right elevator.32 Figure 13: Recovery of flight recorders.33 Figure 14 : Boeing 737-400 overhead instrument panel.38 Figure 15: Combination local track and system track . .47 v LIST OF APPENDI
21、XES Appendix A: Aircraft parts found floating in the sea between Majene and Barru.71 Appendix B: Quick Reference Handbook Chapter 11, page 11.5 from .75 Appendix C: Quick Reference Handbook Chapter 11, pages 11.4 and 11.5 used by AdamAir pilots for training reference.76 Appendix D: Human Factors.78
22、Appendix E: IRS Display Unit and IRS Mode Selector Unit .84 vi LIST OF FIGURES APPENDIX A Figure A1 : Map of parts found floating in the sea between Pare-pare and Baru, South Sulawesi .71 Figure A2 : Part of right elevator showing upper surface (Red arrows point to hinges). Found floating in the sea
23、 close to Sulawesi island (between Pare-pare and Baru, South Sulawesi) Makassar Strait.71 Figure A3 : Part of Left Elevator showing upper surface. Found floating in the sea off the coast near Pare-Pare .72 Figure A4 : Part of left elevator showing lower surface. Found floating in the sea off the coa
24、st near Pare-Pare .72 Figure A5 : Part of elevator tab. Found floating in the sea off the coast near Pare-Pare 73 Figure A6 : Part of elevator tab. Found floating in the sea around Pare-pare .73 Figure A7 : Flight spoiler (showing lower surface) found floating in the sea off the coast of Pare-pare .
25、73 Figure A8 : Flight spoiler as in figure B7 (showing lower surface).74 Figure A9 : Seatback tray tables and seat cushions.74 vii GLOSSARY OF ABBREVIATIONS AD : Airworthiness Directive AFM : Airplane Flight Manual AGL : Above Ground Level ALAR Approach-and-Landing Accident Reduction AMSL : Above Me
26、an Sea Level AOC : Air Operator Certificate ATC : Air Traffic Control ATPL : Air Transport Pilot License ATS : Air Traffic Service ATSB : Australian Transport Safety Bureau Avsec : Aviation Security BMG : Badan Meterologi dan Geofisika BOM : Basic Operation Manual CAMP : Continuous Airworthiness Mai
27、ntenance Program CASO : Civil Aviation Safety Officer CASR : Civil Aviation Safety Regulation CPL : Commercial Pilot License COM : Company Operation Manual CRM : Cockpit Recourses Management CSN : Cycles Since New CVR : Cockpit Voice Recorder DFDAU : Digital Flight Data Acquisition Unit DGCA : Direc
28、torate General Civil Aviation DME : Distance Measuring Equipment EEPROM : Electrically Erasable Programmable Read Only Memory EFIS : Electronic Flight Instrument System EGT : Exhaust Gas Temperature EIS : Engine Indicating System FL : Flight Level F/O : First officer or Copilot FDR : Flight Data Rec
29、order FOQA : Flight Operation Quality Assurance GPWS : Ground Proximity Warning System Hrs : Hours viii ICAO International Civil Aviation Organization IFR : Instrument Flight Rules IIC : Investigator in Charge ILS : Instrument Landing System Kg : Kilogram(s) Km : Kilometer(s) Kts : Knots (nm/hours)
30、Mm : Millimeter(s) MTOW : Maximum Take-off Weight Nm NTSB : Nautical mile(s) National Transportation Safety Board (USA) KNKT / NTSC : Komite Nasional Keselamatan Transportasi / National Transportation Safety Committee C : Degrees Celsius PIC : Pilot in Command QFE : Height above airport elevation (o
31、r runway threshold elevation) based on local station pressure QNH : Altitude above mean sea level based on local station pressure RESA : Runway End Safety Area RPM : Revolution Per Minute ROV : Remotely Operated Vehicle SCT : Scattered S/N : Serial Number SSCVR : Solid State Cockpit Voice Recorder S
32、SFDR : Solid State Flight Data Recorder TS/RA : Thunderstorm and rain TAF : Terminal Aerodrome Forecast TPL : Towed Pinger Locator TSN : Time Since New TT/TD : Ambient Temperature/Dew Point TTIS : Total Time in Service UTC : Universal Time Coordinate VFR : Visual Flight Rules VMC : Visual Meteorolog
33、ical Conditions 1 SYNOPSIS On 1 January 2007, a Boeing Company 737-4Q8 aircraft, registered PK-KKW, operated by Adam SkyConnection Airlines (AdamAir) as flight number DHI 574, was on a scheduled passenger flight from Surabaya (SUB), East Java to Manado (MDC), Sulawesi, at FL 350 (35,000 feet) when i
34、t disappeared from radar. The aircraft departed from Djuanda Airport, Surabaya at 05:59 Coordinated Universal Time (UTC) under the instrument flight rules (IFR), with an estimated time of arrival (ETA) at Sam Ratulangi Airport, Manado of 08:14. The pilot in command (PIC) was the pilot flying for the
35、 sector to Manado and the copilot was the monitoring/support pilot. There were 102 people on board; two pilots, 4 cabin crew, and 96 passengers comprised of 85 adults, 7 children and 4 infants. The Indonesian Navy, Army, Air Force, Police, and Search and Rescue organization, a Singaporean Air Force
36、Fokker 50 aircraft, the USNS Mary Sears, National Transportation Safety Committee of Indonesia, Air Accident Investigation Bureau of Singapore, Singapore Navy Divers, and other resources searched for the wreckage of PK-KKW in the Makassar Strait, in the vicinity of the last radar return. Nine days a
37、fter the aircraft disappeared, wreckage was found in the water and on the shore along the coast near Pare-Pare, Sulawesi. Locator beacon signals from the flight recorders were heard on 21 January 2007 and their positions logged. The attempt to recover the recorders was suspended when it was determin
38、ed that the wreckage was located in the ocean at a depth of about 2,000 meters, requiring specialized recovery equipment not available in the Region. The salvage operation to recover the flight recorders commenced on 24 August 2007 and the DFDR and CVR were recovered on 27 and 28 August 2007 respect
39、ively. The CVR revealed that both pilots were concerned about navigation problems and subsequently became engrossed with trouble shooting Inertial Reference System (IRS) anomalies for at least the last 13 minutes of the flight, with minimal regard to other flight requirements. This included identifi
40、cation and attempts at corrective actions. The DFDR analysis 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 maintain wings level. Following the crews selection of the number-2 (right) IRS Mode Selector U
41、nit to ATT (Attitude) mode, the autopilot disengaged. The control wheel (aileron) then centered and the aircraft began a slow roll to the right. The aural alert, BANK ANGLE, sounded as the aircraft passed 35 degrees right bank. The DFDR data showed that roll rate was momentarily arrested several tim
42、es, but there was only one significant attempt to arrest the roll. Positive and sustained roll attitude recovery was not achieved. Even after the aircraft had reached a bank angle of 100 degrees, with the pitch attitude approaching 60 degrees aircraft nose down, the pilot did not roll the aircrafts
43、wings level before attempting pitch recovery in accordance with standard operating procedures. The aircraft reached 3.5g, as the speed reached Mach 0.926 during sustained nose-up elevator control input while still in a right bank. The recorded airspeed exceeded Vdive (400 kcas), and reached a maximu
44、m of approximately 490 kcas just prior to the end of recording. 2 A thump, thump sound was evident on the CVR about 20 seconds from the end of the recorded data. Flight recorder data indicated that a significant structural failure occurred when the aircraft was at a speed of Mach 0.926 and the fligh
45、t load suddenly and rapidly reversed from 3.5g to negative 2.8 g. This g force and airspeed are beyond the design limitations of the aircraft. At the time of the thump, thump sound, the aircraft was in a critically uncontrollable state. The PIC did not manage task sharing and crew resource managemen
46、t practices were not followed. There was no evidence that the pilots were appropriately controlling the aircraft, even after the BANK ANGLE alert sounded as the aircrafts roll exceeded 35 degrees right bank. This accident resulted from a combination of factors, including the failure of the pilots to
47、 adequately monitor the flight instruments, particularly during the final 2 minutes of the flight. Preoccupation with a malfunction of the Inertial Reference System (IRS) diverted both pilots attention from the flight instruments and allowed the increasing descent and bank angle to go unnoticed. The
48、 pilots did not detect and appropriately arrest the descent soon enough to prevent loss of control. At the time of the accident, AdamAir did not provide their pilots with IRS malfunction corrective action training in the simulator, nor did they provide aircraft upset recovery training in accordance
49、with the Airplane Upset Recovery Training Aid developed by Boeing and Airbus. In accordance with Civil Aviation Safety Regulations, Indonesian operators are required to provide training in emergency or abnormal situations or procedures. However, at the time of the accident, the Indonesian regulation
50、s did not specifically require upset recovery to be included in their flight operations training. Technical log (pilot reports) and maintenance records showed that between October and December 2006, there were 154 recurring defects, directly and indirectly related to the aircrafts Inertial Reference