Adam Air Flight 574

Adam Air Flight 574 (KI-574) was a scheduled domestic passenger flight operated by Adam Air between the Indonesian cities of Surabaya (SUB) and Manado (MDC) that disappeared near Polewali in Sulawesi on 1 January 2007. The plane, a Boeing 737-4Q8, was ultimately determined to have crashed into the ocean, from which some smaller pieces of wreckage have been recovered. The flight recorders ("black boxes") were retrieved from the ocean on 28 August 2007, while salvage efforts for some larger pieces of wreckage continued. All 102 people on board died. This is the highest death toll of any aviation accident involving a Boeing 737-400. A full national investigation was immediately launched into the disaster, uncovering multiple maintenance issues concerning the airline as a whole, including a large number concerning the aircraft. Another possibility proposed by the families of some of the deceased is that the crash was due to a faulty rudder valve, known to have caused previous accidents and incidents on Boeing 737s. Debris location has indicated that the plane likely struck the ocean intact. 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 reference system and inadvertently disconnected the autopilot.

The crash is one of several transportation accidents, including the subsequent non-fatal crash of Adam Air Flight 172, which between 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 would later declare bankruptcy.

Aircraft
The aircraft, a Boeing 737-4Q8, registration PK-KKW, was manufactured in 1990. Prior to service with Adam Air, the plane had flown for seven other airlines: Dan-Air, British Airways, GB Airways, National Jets Italy, WFBN, Air One, and Jat Airways, carrying four different registration numbers, including PK-KKW. 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.


 * Model: Boeing 737-4Q8
 * Registration: PK-KKW
 * MSN/CN: 24070
 * Previous Registrations: YU-AOO, EI-CXH, N112TR, G-BNNL
 * Engine: CFM International CFM56-3C1

Flight chronology
On 1 January 2007, at 12:55 local time (05:55 UTC), the plane departed from Juanda Airport, Surabaya, with 96 passengers (85 adults, 7 children and 4 infants) and six 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 14:53 local time (06:53 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. In his last radio transmission, the pilot reported the crosswinds to be coming from the left, but air traffic control claimed that the winds should be coming from the right. It is not yet known if this is significant to the accident, but it may indicate navigational error, or an emergency turn-around of the aircraft.

Contrary to early reports, no calls for help were sent by the aircraft.

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 mobilization 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 rumors 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 only 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 amongst many vehicles dispatched to aid searching for the missing plane from the air. Indonesian sonar-equipped military aircraft and ships capable of detecting underwater metallic objects later joined the team, equipped with two mini remote-controlled submarines. These searched the sea for five days between 3 January 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 have 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 U.S.$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, finalizing 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.

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 miles) 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 U.S. Navy ship, USNS 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 U.S., 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 analyzed to confirm it belongs to the 737.

Floating debris
The aircraft's right horizontal stabilizer was found by a fisherman, south of Pare Pare, about 300 metres (984 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 realizing it was a piece of the tail. This was confirmed by the serial number on the stabilizer, 65 C 25746 76, which matches 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 aluminum and fiber, an ID card, a flare and a headrest have also been recovered from the area. By 13 January, a piece of a wing was also recovered. It is unclear whether the 1.5 metres (4.9 ft) long section is 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, the flight data recorder (FDR) and cockpit voice recorder (CVR), colloquially called black boxes, were located off the coast of West Sulawesi by the U.S. vessel Mary Sears. The flight data recorder was located at 03°41′02″S 118°08′53″E﻿ / ﻿3.68389°S 118.14806°E﻿ / -3.68389; 118.14806 at a depth of 2,000 metres (6,600 ft), while the cockpit voice recorder was located at 03°40′22″S 118°09′16″E﻿ / ﻿3.67278°S 118.15444°E﻿ / -3.67278; 118.15444 at a depth of 1,900 metres (6,200 ft). These positions indicate the black boxes are located approximately 1.4 km (0.87 mi) apart. The Indonesian vessel Fatahillah travelled to the location, while Mary Sears traveled to Singapore, arriving on 29 January to return the detector equipment used to locate the devices. 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 is now considered to be all that remains of the aircraft. A senior Indonesian marine official said on January 24 that he did not believe the equipment which is necessary to retrieve the boxes from that depth is available in any Asian country. The black boxes had a battery life of just 30 days, and were subsequently 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, 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 required 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 U.S. National Transportation Safety Board, said that it was essential the boxes were recovered quickly, as at that point their 30-day battery life was about to expire, which it subsequently did. 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 $100,000 per day to hire in an operation that would take around ten days, equating to U.S.$1 million.

On 31 January it was reported that the U.S. had to withdraw the vessel Mary Sears from the searches, the U.S. military saying that the vessel had other duties. Further funding and help from the U.S. would have to be approved by the Congress. At the same time external companies were suggested as possible retrievers of the black boxes. Indonesia continued to seek help from other countries, like 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, neither could they force Adam Air to. 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. However, 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 can dive up to 6,000 metres (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 metres (6,500 ft) and were 1,400 metres (4,600 ft) apart. They had been moved 10–15 metres (33–49 ft) from their original locations by powerful underwater currents. The black boxes were sent to Washington for analysis, there was fear that the recovery efforts could fail due to data destruction caused by the long submersion. 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 for 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 airplane 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. Patrick Smith, a U.S.-based airline pilot and aviation commentator, has said that "Whatever happened to the plane, it was likely rapid and catastrophic," and said that an on-board explosion or metal fatigue-induced structural failure were the most likely causes of the accident. There will also be a wider investigation into Indonesia's transport system as a whole. Eyewitnesses have 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 KNKT, responsible for the investigation, said that even if the flight recorders are not retrieved they 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 experienced an in flight breakup prior to 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 believe it may have played an important factor in the accident.

Adam Air as a whole
The safety record of Adam Air has been heavily criticized. Adam Air has reportedly bribed pilots to fly planes they knew were unsafe. 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 airplane is ascending or descending. A total of 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. Most notably, 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 two complaints that the weather radar was faulty.

Legal action
Adam Air is being sued by Indonesian consumer and labor 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 over the accident instead of Adam Air. 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.

Political
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 organizations 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 deceased 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 fulfil the request.

Aftermath
The Indonesian government announced plans immediately after the accident to ban jets over ten years of age for any commercial purpose. The age limit was previously 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 will have their licenses revoked within three months unless they could improve their safety standards. 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 has 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 U.S. 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.

Flight 172
On 21 February 2007, just 51 days after the loss of Flight 574, Flight 172, an Adam Air Boeing 737–300 aircraft (registration PK-KKV) flying from Jakarta to Surabaya had a hard landing at Juanda International Airport. The incident caused the fuselage of the plane to crack and bend in the middle, with the tail of the plane drooping towards the ground. There were no reports of serious injuries from the incident. As a result, six Adam Air 737s were grounded awaiting safety checks. Adam Air described this as "harsh punishment" for an accident it blamed on poor weather conditions, but Vice President Jusuf Kalla had said that all Boeing 737-300s should be checked.

Alleged Cockpit Voice Recording Leakage
In early August 2008, a five-minute-38-second digital recording allegedly retrieved from the plane's cockpit voice recorder was widely circulated on the Internet and transcribed by the media. The recording, which had been publicly distributed through chain e-mails, begins with what is believed by some to be a conversation between pilot Refi Agustian Widodo and copilot Yoga Susanto before the crash. Approximately two minutes before the end of the recording the autopilot disconnect horn sounded, followed approximately a minute later with "bank angle" warnings from the GPWS and the altitude alerter. Immediately thereafter, as the airplane began its final dive, the shotgun-like sounds of engine compressor surges and the overspeed "clacker" could be heard along with two background voices screaming in terror, and shouting out the name of God. Towards the end of the recording there is a dramatic increase in windshield noise and two loud bangs (the second larger than the first) consistent with structural failure of the airplane, followed 20 seconds later by an abrupt silence. Likely, when the pilots regained visual ground contact, they quickly pulled up, overloading the horizontal stabilizer downwards and a main wing spar upwards. It was dismissed by the officials who said that it was not authentic and was not the original recording.

Dramatization
The crash was the subject of a Season 7 Episode of Mayday (also known as Air Crash Investigation) entitled 'Flight 574: Lost' (also aired as The Plane That Vanished in some countries).