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National Transportation Safety Committee Ministry of Transportation Republic of Indonesia 2008

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National Transportation Safety Committee Ministry of Transportation Republic of Indonesia 2008 Aircraft Accident Investigation Report KNKT/07.01/08.01.36 NNAATTIIOONNAALL TTRRAANNSSPPOORRTTAATTIIOONN SSAAFFEETTYY CCOOMMMMIITTTTEEEE BOEING 737–4Q8 PK–KKW MAKASSAR STRAIT, SULAWESI REPUBLIC OF INDONESIA 1 JANUARY 2007 NATIONAL TRANSPORTATION SAFETY COMMITTEE MINISTRY OF TRANSPORTATION REPUBLIC OF INDONESIA 2008 This report was produced by the National Transportation Safety Committee (NTSC), Karya 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 Regulation (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 greatest 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. ISBN: 978–979–16958–1–7 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 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. 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 SYNOPSIS ...............................................................................................................................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 1.6.3 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 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 i 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 SkyConnection 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 Electronic 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 Assessment ― 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 Human 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
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