By TOM WRIGHT, The Wall Street Journal, March 25, 2008 7:17 a.m.
JAKARTA, Indonesia -- The Adam SkyConnections Airlines flight which crashed on New Year's Day 2007, killing all 107 people on board, was caused by a navigational systems error that distracted the pilots from the job of flying the plane, the Indonesian government said in a report published Tuesday.
"The cockpit voice recorder revealed that both pilots were concerned about navigational problems and subsequently became engrossed with troubleshooting … with minimal regard for other flight requirements," the government report found. The Adam Air plane, a Boeing 737-400, crashed in to the sea off the coast of Sulawesi, an island northeast of Jakarta.
The unusually blunt and detailed report is the latest evidence that Indonesia's government is taking safety more seriously after a report in November by the International Civil Aviation Organization, a United Nations body that sets global standards for the industry, lambasted the nation's inadequate regulation of airline operators. Both the U.S. Federal Aviation Administration and the European Commission have downgraded Indonesia's safety record in the past 12 months, meaning the nation's carriers are banned from flying to either the U.S. or Europe.
The industry has suffered a string of deadly crashes since Indonesia's government liberalized the aviation sector a few years ago, leading to an explosion of new local carriers. Last March, a flight operated by state-owned PT Garuda Indonesia crashed while landing at Yogyakarta's airport, killing 21 people. In 2005, a Mandala Airlines plane plowed in to a suburb of Medan, a city in north Sumatra, killing 150 people. It crashed shortly after takeoff, apparently due to engine failure.
The spate of incidents has put pressure on Indonesia's government to act. The Transport Ministry last week took the unusual step of banning Adam Air from flying, citing poor aircraft maintenance and pilot training, and gave the airline three months to improve or have its operating license revoked.
In the past, many reports on Indonesian crashes have either never been completed or buried inside the government. The Adam Air crash report, coming after a similarly detailed one on the Garuda incident published late last year, appears to be another sign of increased regulatory vigilance.
Tuesday's report sets out in detail how Adam Air's failure to address persistent technical problems with its aircraft, coupled with insufficient pilot training, led to the crash. The airline, founded in 2003 by Indonesia's Suherman family, has been involved in a number of incidents since it began operations.
On Jan. 1, 2007, Adam Air Flight 574 took off from Surabaya on Indonesia's main island of Java for Manado on the northern tip of Sulawesi, a tourist resort popular with scuba divers. About 45 minutes into the flight, the pilots began to notice problems with the plane's navigational device, known as the Inertial Reference System.
The National Transport Safety Committee, an arm of Indonesia's Transport Ministry charged with investigating transport disasters, said the cockpit voice recording showed the pilots were trying to fix the system "for at least the last 13 minutes of the flight."
Shortly before the plane crashed in to the sea, the pilots became concerned that the navigational system wasn't working, telling each other "this is messed up," "we can get lost if it's like this" and "she's starting to fly like a bamboo ship," according to a transcript of the cockpit voice recorder published in the report. The last recording was of the co-pilot shouting "pull up" repeatedly as the plane lost altitude.
Logs for the 737-400 showed that various Adam Air pilots had registered problems with the navigation system 154 times in the three months leading up to the crash, but insufficient action had been taken to solve the problem. "There was also no evidence of Adam Air's maintenance management controlling the repetitive defects on their fleet prior to the accident," the report said.
The pilots tried to reset the system, causing the autopilot to disengage automatically and the aircraft began to veer to the right, the report found. An alert sounded in the cockpit as the aircraft banked more than 35 degrees. The plane also began to lose altitude, with the aircraft's nose pointing down 65 degrees from horizontal.
To correct the situation, the pilots attempted to bring the nose up without first leveling the wings "in accordance with standard procedure," the report said. The plane then flew out of control, spiraling downward and leading to "significant structural failure" due to increased airspeed and g-force that were "beyond the design limitations of the aircraft."
"There was no evidence that the pilots were appropriately controlling the aircraft, even after the bank angle alert sounded," the safety committee said.
Initially, Adam Air had blamed inclement weather for the crash, which happened during the onset of Indonesia's monsoon season. The report said it was unable to determine the exact weather at the time of the crash, but added that visibility was "marginal" due to rain and cloud.
After the crash, it took nine days before investigators found wreckage of the plane washed up along the coast of Sulawesi. The exact location of the plane wasn't pinpointed until Jan. 27, almost a month after the crash. The fragmented remains of the craft were lying on the seabed some 2,000 meters below sea level. It took investigators until August to recover the flight data and cockpit voice recorders.
Analysis of the digital flight data recorder showed the plane had hit the sea at a steep impact angle and at high speed. Some personal effects of the victims like luggage and school bags were found but no human remains, the report said.
Write to Tom Wright at email@example.com