Adam Air Flight 574

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01.01.2007
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Adam Air Flight 574 (KI574 or DHI574) was a scheduled domestic passenger flight operated by Adam Air between the Indonesian cities of Surabaya (SUB) and Manado (MDC) that crashed into the Makassar Strait near Polewali in Sulawesi on 1 January 2007. All 102 people on board died, the highest death toll of any aviation accident involving a Boeing 737-400. A full national investigation was immediately launched into the disaster. The final report, released on 25 March 2008, concluded that the pilots lost control of the aircraft after they became preoccupied with troubleshooting the inertial navigation system and inadvertently disconnected the autopilot. It was the only fatal accident for Adam Air in the 3-year history of the company.

The crash is one of several transportation accidents, including the subsequent non-fatal crash of Adam Air Flight 172, which among them have resulted in large-scale transport safety reforms in Indonesia, as well as the United States downgrading its safety rating of Indonesian aviation, and of the entire Indonesian fleet being added to the list of air carriers banned in the EU. Adam Air was subsequently banned from flying by the Indonesian government, and later declared bankruptcy.

History

Aircraft

The aircraft, a Boeing 737-4Q8, serial number 24070, registration PK-KKW, was manufactured in 1989. Prior to service with Adam Air, owned by ILFC the aircraft had been leased to seven airlines: Dan-Air, British Airways, GB Airways, National Jets Italy, WFBN, Air One and Jat Airways. The plane had 45,371 flying hours and was last evaluated and declared airworthy by the Indonesian transport ministry on 25 December 2005. It was due to be checked again in late January 2007. The Surabaya airport duty manager said that there were no technical problems with the aircraft prior to departure.

Flight deck crew

The captain was 47-year-old Refri Agustian Widodo from Sidoarjo, Indonesia, who joined Adam Air in 2006. The first officer was 36-year-old Yoga Susanto, an employee of Adam Air since 2006. Captain Widodo was a seasoned veteran, having logged more than 13,300 hours of flying time. As pilot-in-command of Boeing 737 aircraft, he had more than 3,800 hours of experience. First Officer Susanto had 4,200 total flying hours and he had almost 1,000 hours logged as a Boeing 737 first officer.

Flight chronology

On 1 January 2007, at 12:59 local time (05:59 UTC), the plane departed from Juanda Airport, Surabaya, with 96 passengers (35 adults, 47 children and 4 infants) and 6 crew on board. The passenger list was composed mainly of Indonesian nationals; the only foreigners were an American family of three. The two-hour flight, scheduled to arrive at Sam Ratulangi Airport, Manado, at 16:00 local time, was as expected until the plane disappeared from air traffic control radar screens at Makassar, South Sulawesi, with the last contact at 14:56 local time (06:56 UTC). The last known beacon position was detected by a Singaporean satellite. The altitude of the plane was shown as 35,000 feet (10,670 m) on the radar screen.

Weather in the region was stormy; the Indonesian Bureau of Meteorology and Geophysics noted that the cloud thickness was up to 30,000 feet (9,140 m) in height and wind speed at an average of 30 knots (56 km/h) in the area. Although the Juanda Airport operator, PT Angkasa Pura I, had given warnings to the pilot concerning the weather condition, the plane had departed as scheduled. The plane ran into crosswinds of more than 70 knots (130 km/h) over the Makassar Strait, west of Sulawesi, where it changed course eastward toward land before losing contact.

No calls for help were sent by the aircraft.

Search and rescue efforts

False reports of discovery

Initial reports indicated that the plane had been located in the mountainous region of Sulawesi around 20 kilometres (12 mi) from Polewali town and that there were 12 survivors. This led to the mobilisation of an Indonesian Air Force plane carrying hundreds of search and rescue personnel. However the team found no sign of aircraft wreckage at the reported crash site. On 2 January 2007, the Indonesian transport minister confirmed that the plane had not yet been found and reports to the contrary were based on false rumours from local villagers passed on to local officers. It later turned out that the 12 reported survivors were actually from the MV Senopati Nusantara, which sank two days earlier during the same storm.

Continued efforts

A search and rescue team 3,600 members strong was mobilised. One Boeing 737-200 Surveiller (a military surveillance plane), two infrared-equipped Fokker-50 aircraft from the Republic of Singapore Air Force, a Navy Nomad plane and six helicopters were dispatched to aid searching for the missing plane from the air. The Indonesian sonar-equipped ship Pulau Rengat, capable of detecting underwater metallic objects later joined the team, equipped with a mini remote-controlled submarine. It searched the sea for five days between 3 and 8 January, without success.

Naval ships combed the Makassar Strait while military personnel went through jungles and mountains of Sulawesi. In the face of heavy rain and strong winds in the area, the search efforts, coordinated from Makassar city, were focused in the area between the coastal town of Majene and the mountainous region of Toraja. The search in the two areas was due to twin signals, each carrying different emergency locator transmitter frequencies, received by the Singaporean satellite and an Indonesian military air base. The two separate locations produced on radar screens were a spot on the sea in Majene and on land in Rantepao, Tana Toraja. Searches were then expanded throughout the Island of Sulawesi; some were triggered by unknown distress signals received by a commercial Lion Air flight and an airport. A police officer at the Barru district police operational centre said that all the districts with stretches of coastline along the Makasser Strait had teams searching for the plane.

There were fears that the plane's tracking equipment and emergency locator beacon could have been damaged after the crash or weakened by interference, and that this would hamper the search. The head of the National Search and Rescue Agency told the Associated Press that he believed the aircraft was probably lost at sea. From 5 January 2007, the main focus of the search was relocated to areas south of Manado, after Manado's Sam Ratulangi Airport reported detecting a signal from the plane a day before. However, the rugged terrain coupled with thick and low hanging clouds continued to hamper the search efforts, and three relatives of missing passengers who overflew part of the area on a military reconnaissance plane admitted that the chances of finding the plane were slim. Officials said that it was unlikely any bodies had survived in one piece. On 14 January, at Indonesia's request, Singapore sent four towed underwater locator beacon detectors, sometimes called Towed Pinger Locators, and six consultants in their use to aid in the search. These would successfully locate the black boxes. On 24 January, the British ship MN Endeavour joined the search. The ship is operated by local mining firm PT Gema Tera Mustikawati and is usually used by oil and gas drilling companies to map the seabed. By 24 January, the Indonesian government had spent an average of Rp 1 billion (about US$110,000) a day on the search.

On 10 February, search operations were officially halted by the Search and Rescue Agency, according to Transportation Minister Hatta Rajasa, finalising the legal status of both the plane and its passengers and crew. This announcement allowed the families of the victims to start the insurance claims process.

Discovery of wreckage

Unidentified submerged objects

On Monday, 8 January, three large metal objects, suspected to be wreckage, were detected by the Indonesian ship KRI Fatahillah's sonar. First Admiral Gatot Subyanto of the Indonesian Navy indicated three locations, between 3–6 km (2–4 mi) apart, off Mamuju city on Sulawesi's western coast. Due to limitations of the navy's sonar equipment, it was not clear what the metal was, and Indonesia had no other equipment of its own. A US Navy ship, Mary Sears, arrived in the area on 9 January with better equipment to help identify the objects, and on the same date a Canadian jet with five separate air crews, working in shifts, was sent to aid with aerial mapping of the suspected location. The Indonesian Marine and Fishery Department has since suggested that the metal objects could instead be instruments deployed to study the underwater sea current. A total of twelve Indonesian Navy ships were deployed in the area, including the KRI Ajak, KRI Leuser and KRI Nala. Extra underwater equipment, including a metal detector and an undersea camera, was sent from the US, and arrived aboard the USNS Mary Sears on 17 January. The black boxes were subsequently located elsewhere, in the waters in an area known as Majene, and a wide, sweeping search of the area revealed high amounts of scattered debris there, too. This debris was analysed to confirm it belonged to the 737.

Floating debris

The aircraft's right horizontal stabiliser was found by a fisherman, south of Pare Pare, about 300 m (980 ft) off the beach on 11 January, although it was not originally handed in, as its discoverer thought it to be a piece of plywood, only later realising it was a piece of the tail. This was confirmed by the serial number on the stabiliser, 65 C 25746 76, which matched that of components on the missing 737. The fisherman received a reward of 50 million rupiah (equivalent to about $5,500) for his discovery. Later, other parts of the aircraft, including passenger seats, life jackets, a food tray, part of an aircraft tire, eight pieces of aluminium and fibre, an ID card, a flare and a headrest were also recovered from the area. By 13 January, a piece of a wing was also recovered. It is unclear whether the 1.5-metre (4 ft 11 in) long section was a section of the right wing or the left wing, although it was examined in an attempt to discover this. The total count of recovered objects associated with aircraft, as of 29 January, was 206, of which 194 were definitely from the 737. On 15 January, an unidentified fuel spill was spotted by the Singaporean reconnaissance aircraft along the western coast of Sulawesi, but by the time a ship arrived to attempt to determine whether the spill came from the aircraft, it had been moved by strong currents. Although it was searched for, it was not relocated. Pieces of clothing thought to belong to passengers were also recovered, and on 15 January, pieces of human hair and what is thought to be human scalp were recovered from a headrest that had been pulled from the sea. They were DNA tested to attempt to identify them; the results of this test are, however, unknown.

Black boxes

On 21 January 2007, the flight data recorder (FDR) and cockpit voice recorder (CVR), colloquially called black boxes, were located off the coast of West Sulawesi by the US vessel Mary Sears.[60] The flight data recorder was located at 03°41′02″S 118°08′53″E at a depth of 2,000 m (6,600 ft), while the cockpit voice recorder was located at 03°40′22″S 118°09′16″E at a depth of 1,900 m (6,200 ft). These positions indicate the black boxes were located approximately 1.4 km (0.87 mi) apart. The Indonesian vessel Fatahillah travelled to the location, while Mary Sears travelled to Singapore, arriving on 29 January to return the detector equipment used to locate the devices.[60] It did not travel immediately to Singapore because it was mapping the immediate area. The Mary Sears used its side scan sonar (SSS) unit to map an area of approximately 10.3 km² (3 sq nmi) around the recorders in high resolution, an operation which required 18 passes across the area at approximately 3 knots (6 km/h), taking six hours per pass including lining up for the next pass. It discovered a large amount of wreckage in the area, which was considered to be all that remained of the aircraft. A senior Indonesian marine official said on 24 January that he did not believe that the equipment required to retrieve the boxes from that depth was available in any Asian country.[62] The black boxes had a battery life of just 30 days, and would subsequently be unable to emit locator signals.

On 3 February, Indonesian naval vessel KRI Tanjung Dalpele took affected families out to the crash site where a memorial service was held, which included throwing flowers into the sea.

Salvage

On 26 January 2007, a dispute arose between Adam Air and the Indonesian government regarding the retrieval of the black boxes. Due to the depth involved, recovery required an underwater remotely operated vehicle, but due to the cost of using this method of recovery—especially since such equipment needed to be shipped in from elsewhere—the government placed the responsibility for the cost of recovering the recorders on Adam Air. Vice-President of Indonesia Jusuf Kalla went as far as to question the need to retrieve the black boxes at all, although experts said in response that the accident was of international significance as it could indicate a fault with the aircraft. Adam Air said that in its opinion, the black boxes should be recovered, describing the accident as being relevant on both national and international levels, but refused to pay, saying that was the responsibility of the government. Indonesia did request technical assistance from the United States, Japan and France. Jim Hall, a former chairman of the US National Transportation Safety Board, said that it was essential the boxes be recovered quickly, as at that point their 30-day battery life was about to expire, which subsequently did happen. He cited problems such as poor visibility and strong currents making it difficult to recover the devices without the signal. Setio Rahardjo, Head of National Committee for Transportation Safety, estimated that equipment for the salvage operation, if available, would cost US$100,000 per day to hire in an operation that would take around ten days, equating to US$1 million.

On 31 January it was reported that the US had to withdraw the vessel Mary Sears from the searches, the US military saying that the vessel had other duties. Further funding and help from the US would have to be approved by the US Congress. At the same time, external companies were suggested as possible retrievers of the black boxes. Indonesia continued to seek help from other countries, such as France and Japan. Setio Rahardjo maintained that Adam Air should be charged with the retrieval costs.

It was originally confirmed that Indonesia would not pay for the salvage operation, and neither could they force Adam Air to do so. On 15 February, it was reported that Adam Air had been in contact with two salvage companies, Smit Internationale and Phoenix International, regarding the salvage operation. It was Phoenix who supplied the Mary Sears with the necessary equipment for the search operation. Adam Air received preliminary invoices and continued negotiations with the two companies. Later, Adam Air announced that they did indeed intend to select a company to conduct the operation shortly and would pay for this themselves.

On 28 May, Adam Air announced they had signed a contract with Phoenix International, with original plans being for the recovery to occur in June, according to Aero News. On 23 August, the Eas arrived in Sulawesi's Makassar port to begin salvage operations, which began with several days survey. The vessel was carrying a mini-submarine that could dive up to 6,000 m (20,000 ft), and was equipped with sonar and deep sea cameras.

A Phoenix International underwater robot scouring the sea off Majene for on Sulawesi finally retrieved the flight data recorder on 27 August and cockpit voice recorder on 28 August. The two devices were found at a depth of around 2,000 m (6,600 ft) and were 1,400 m (4,600 ft) apart. They had been moved 10–15 m (33–49 ft) from their original locations by powerful underwater currents. The black boxes were sent to Washington for analysis. The final cost of the salvage operation to retrieve the black boxes was US$3 million, of which two million was contributed by the Indonesian government, with Adam Air paying the rest. Efforts continued with the hope of recovering various large pieces of wreckage from the seabed.

Investigation

President Susilo Bambang Yudhoyono ordered a full investigation to discover the cause of the aircraft's disappearance, including the cause of any accident it may have had, before the main debris field had even been found. The investigation also looked at the airworthiness of the plane and standard procedure on aircraft operations. A team from the United States with representatives from the National Transportation Safety Board, the Federal Aviation Administration, Boeing and General Electric were sent to Indonesia to assist the Indonesian National Committee for Transportation in the investigation. A wider investigation into Indonesia's transport system as a whole was planned. Eyewitnesses reported seeing a low-flying, unstable aircraft in the area that the wreckage has been recovered from, but lost sight of it after hearing a loud bang. The chief of the Indonesian Plane Technicians group, Wahyu Supriantono, said that the plane was unlikely to have suffered an in-flight break up or explosion as the debris field would have been larger, and as a result, wreckage would have been discovered earlier. The Indonesian National Transportation Safety Committee (NTSC, or KNKT as per its Indonesian name), responsible for the investigation, said that even if the flight recorders were not retrieved, the agency still intended to publish a final report complete with a probable cause, saying they had other "facts and findings" that provide enough information to do so.

On 25 March 2008, the inquiry ruled that pilot error and a faulty navigation device downed the airliner. While cruising at 35,000 feet (10,668 m), the pilots became preoccupied with troubleshooting the aircraft's two inertial reference systems (IRS), part of the navigation system. The autopilot became disengaged and the pilots failed to correct for a slow right roll even after a "bank angle" alarm sounded. Despite the bank angle reaching 100° with almost 60° nose down attitude, the pilots did not level the wings before trying to regain pitch control. The aircraft reached 490 knots (910 km/h) at the end of the recording, in excess of the aircraft's maximum rated speed for a dive (400 knots). The aircraft broke up in flight before impact, at which time the investigators concluded the aircraft was in a "critically unrecoverable state".

Maintenance concerns

Investigators quickly became concerned about apparent poor maintenance and believed it might have been an important factor in the accident.

Adam Air as a whole

The safety record of Adam Air has been heavily criticised. Pilots have reported repeated and deliberate breaches of international safety regulations, and aircraft being flown in non-airworthy states for months at a time. They claim that there have been such incidents as requests to sign documents to allow an aircraft to fly, while not having the authority to, and while knowing the plane to be unairworthy, flying a plane for several months with a damaged door handle, swapping parts between aircraft to avoid mandatory replacement deadlines, being ordered to fly aircraft after exceeding the take-off limit of five times per pilot per day, flying an aircraft with a damaged window, using spare parts from other aircraft to keep planes in the air, and ignorance of pilot's requests not to take off due to unsafe aircraft. The Associated Press quoted one pilot as saying that "Every time you flew, you had to fight with the ground staff and the management about all the regulations you had to violate." They also claimed that if pilots confronted their seniors in the airline, they were grounded or docked pay.

Specific aircraft

Investigators discovered that the aircraft was the subject of a large number of complaints by pilots, called write-ups in the aviation industry. The highest number of complaints concerned the captain's side vertical speed indicator, which informs the air crew of the rate (in ft/min: Feet Per Minute) at which the aircraft is ascending or descending. In all, 48 complaints were made regarding the instrument in the three months before the crash. The aircraft's left right inertial reference system, which informs pilots what direction the aircraft is turning in, was complained about a total of thirty times. The International Herald Tribune reported that this may be of particular significance. The third most-complained about instrument was a fuel differential light, which received fifteen write-ups. Numerous complaints were also received about inoperative cockpit instrument lights, as well as multiple other malfunctions. Several complaints were made that the flaps, which modify drag and lift during take-off and landing, were jamming at twenty-five degrees upon landing, and there were two complaints that the weather radar was faulty.

Legal action

Adam Air is being sued by Indonesian consumer and labour groups over the accident, for a total of one trillion rupiahs (US$100 million), to be paid to the families of the victims. According to a lawyer for the families, speaking in a press conference along with the secretary for the Adam Air KI-574 Passengers' Families Association (formed in the aftermath of the disaster), 30 of the victims' families intend to sue Boeing instead of Adam Air over the accident. However, this does not necessarily mean that all of the others will sue Adam Air, as they may not necessarily exercise their right to sue at all. Representatives of the families have explained that they believe the plane was brought down by a faulty rudder control valve, similarly to the accidents involving United Airlines Flight 585 and USAir Flight 427, which went down in the early 1990s. They have explained that, as a result, they are suing Boeing and Parker Hannifin, the valve's manufacturer, although airlines using the 737 have been warned about problems with the rudder control valves.

Reaction

Government

Vice-President Jusuf Kalla described the disappearance as an "international issue." A few days after the disappearance, President Susilo Bambang Yudhoyono set up the National Team for Transportation Safety and Security, partially as a response to the high number of recent transportation accidents in Indonesia, and partially as a direct response to the event. The team was tasked to evaluate thoroughly the transport safety procedures and review the existing regulations on transportation. It was not, however, to investigate accidents; the entity deemed responsible for this was the Komisi Nasional Keselamatan Transportasi (KNKT), or in English the National Transportation Safety Commission (NTSC), which is part of Departemen Perhubungan (Ministry of Transportation).

Adam Air

Adam Air has been accused by multiple organisations of poor maintenance, and of ordering pilots to fly in all weather and regardless of aircraft conditions. Adam Adhitya Suherman, founder of the family-run airline, has personally denied these accusations, and has said that maintenance consumes "up 40 percent of our total operational costs". Despite this denial of any responsibility for the crash, Adam Air has compensated the families of deceased passengers Rp 500 million (equivalent to about US$55,000 or €42,000) per passenger. It also compensated families of the flight crew.

There has been some call from relatives of the dead for Adam Air to build a memorial to the victims in Makassar, South Sulawesi. Adam Air said that if an agreement could be reached, then they would fulfill the request.

Aftermath

Shortly after the crash, Adam Air changed the number of the regular Surabaya–Manado flight from KI574 to KI582.

The Indonesian government announced plans immediately after the accident to ban jets over ten years of age for any commercial purpose. Previously the age limit was 35 years or 70,000 landings. Although this was in response to a large number of aircraft accidents, it was mainly in response to this accident and the Flight 172 incident. Indonesia also announced that the Transportation Ministry would be reshuffled in response to this accident, Flight 172 and the loss of the ferries MV Senopati Nusantara and Levina 1. Among those replaced were the directors of air and sea transports and the chairman of the National Committee for Transportation Safety. Indonesia also introduced a new system of ranking airlines according to their safety record, with a level one ranking meaning the airline has no serious issues, a level two ranking meaning the airline must fix problems, and a level three rating forcing the airline to be shut down.

On 16 March 2007, the Indonesian government announced plans to shut down an unspecified Indonesian air carrier. It was announced on 22 March that Adam Air was one of seven airlines that would have their licenses revoked within three months unless they could improve their safety standards.[104] The other six airlines involved were Batavia Air, Jatayu Airlines, Kartika Airlines, Manunggal Air Services, Transwisata Prima Aviation and Tri-MG Intra Asia Airlines. The airlines were all targeted as a direct result of the crash, as they were in the third level of the ranking system introduced as a result. All 54 of Indonesia's airlines, including state-owned Garuda Indonesia, were told they would need to make some improvements, with none of them receiving a level one ranking.

It was reported on 28 June 2007, that Adam Air would escape closure and had been upgraded one rank in safety rating, to the middle tier. The airlines that have lost their licenses are Jatayu Gelang Sejahtera, Aviasi Upataraksa, Alfa Trans Dirgantara and Prodexim and the airlines that have been grounded pending improvements and facing potential licence revocation are Germania Trisila Air, Atlas Delta Setia, Survey Udara Penas, Kura-kura Aviation and SMAC.

On 16 April 2007, the American Federal Aviation Administration responded to the results of the new airline survey by downgrading Indonesia's air safety oversight category from a 1 to a 2 because of "serious concerns" over safety. This means it views Indonesia's civil aviation authority as failing to oversee air carriers in accordance with minimum international standards. As a direct result, the US Embassy in Jakarta issued a warning to all American citizens flying in or out of Indonesia to avoid using Indonesian airlines, and instead use international carriers with better safety reputations. This was followed on 28 June 2007 by the addition of all Indonesia's airlines, none of which flew to Europe at the time, to the List of air carriers banned in the EU. Budhi Mulyawan Suyitno, Director-general of civil aviation at the Indonesian transport ministry, responded by saying that he felt Indonesia had made the improvements required by the EU.

Adam Air ceased operation on 18 March 2008 after its Air Operator's Certificate was suspended by the Indonesian government, and was officially suspended permanently on 18 June 2008.

 

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