Analysis Of An Aircraft Accident



In the past couple of years, there are numerous aircraft accidents which have taken place either due to human error or instrumentation failure. There are some common reasons behind plane crashes. At first, emphasis needs to be placed on the pilot error. It is the sole responsibility of a pilot to efficiently respond to various mechanical issues, execute a safe landing and take-off and navigate through any kind of dangerous weather. Mechanical error contributes towards 22% of aviation accidents. There is a difference between pilot error and mechanical error. It is evident that when there is a critical system failure, then pilots are unable to maintain safety conditions. Mechanical errors usually emerge when there is some sort of significant failure within the plane’s design. Weather conditions form another threat which can lead to severe plane crashes. For instance, lighting strikes can make a plan disable. Electrical failures are caused by lighting, because it ignites pipes and fuel tanks. On the other hand, mistakes of air traffic controllers have also caused aircraft accidents. The focus of this study will be to closely scrutinize the key reasons which resulted into the accident of Adam Air Flight 574.


Brief description about the accident

Adam Air Flight 574 was a domestic passenger flight that was operated by Adam Air, between the two well-known Indonesian cities i.e. Manado (MDC) and Surabaya (SUB). The aircraft met with an accident near Sulawesi in the Makassar Strait, in the year 2007. There were 102 people on board and all of them died in the plane crash (Dekker, 2016).  This particular aircraft crash was denoted as the accident with highest death toll, comprising of Boeing 737-400. The incident is even referred to as the third-deadliest aviation accident which occurred in 2007, first and second position occupied by Kenya Airways Flight 507 and TAM Airlines Flight 3054 respectively.  The disaster was scrutinised from multiple perspectives. A national investigation team was appointed in order to figure out the main reasons which caused the disaster. In an investigation brief, it was revealed that the pilots were unable to control the system due to certain technical failures. The pilots eventually got engaged in resolving issues related to the inertial navigation system and even disconnected their connection with autopilot (Shappell and Wiegmann, 2012).  In the history of the company, this was probably the only fatal accident which had taken place. At the initial stage, the investigation clearly revealed that the accident was due to couple of reasons, such as pilot error, malfunctioning of inertial reference system and spatial disorientation.  The main reason behind the accident could not be determined by the investigators in the preliminary phase. Adam Air Flight 574 crash was among the several transportation accidents which have occurred across the globe. It can be stated that these crashes have triggered establishment of safety reforms in large-scale transport in U.S. and Indonesia. There is a wide base of Indonesian fleet which currently falls under the category of banned air carriers in EU. Adam Air was declared to be banned by the Indonesian government and gradually the aircraft company entered into the phase of bankruptcy (Gibson, 2010).  Criticisms have been raised against safety record of the aircraft. There were defaults in the aircraft design which further degraded the safety standards of the fleet.

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Main reasons behind the accident

The series of incidents which led to the disaster highlight that there was human error combined with technical faults. A detailed investigation about the occurrence of the disaster was carried on for one year. On the basis of investigation report, it can be revealed that faulty navigation equipment and certain amount of pilot error was probably the key reasons behind this crash. At approximately 35,000 feet, the pilot was found to be busy with two inertial reference systems (IRS) of aircraft and even significant part of the entire navigation system. The pilot eventually got disconnected from the autopilot.  As per the report, the pilot failed to rectify the slow right roll even after the alarm made sound. The bank angle had reached 100degrees to nearby 60degrees nose down, but the wings could not be boosted to regain pitch control efficiently. It was identified that the aircraft had reached around 490 knots, in reference to the end of the tape (Roelen, Lin and Hale, 2011).   On the other hand, the maximum rated speed which was observed for an aircraft was approximately 400 knots. There was structural failure also encountered by the aircraft for around 20 seconds, prior to reaching the tape end.  The first trouble emerged when the aircraft was not able to follow the programmed route. The pilots changed the IRS mode selector successfully into the attitude mode. It caused several forms of displays, such as loss of pitch and horizon scales, roll indication, etc. The autopilot began to get disengaged and slowly the aircraft moved towards the right direction. Visual navigation became slowly impossible as the aircraft was passing through stormy clouds. The pilots became spatially disoriented and eventually lost control over the system (Griffin, Young and Stanton, 2010).  At this instance, the autopilot control was completely disrupted and the aircraft was observed to take a right roll. However, an alert was communicated to the pilot of the right bank angle, but the inputs were relatively insufficient so as to regulate the roll rate. When the aircraft started to roll towards the right direction, then the pilots could determine that it was an unsafe attitude and incorrect control inputs were used. The aircraft finally flew into the ocean. It was assumed that the crew was inefficient in communication and task sharing. Hence, they were unable to undertake the decision at the right moment.

Procedural violation or instrument failure

The initial details of the aircraft crash signify that it was a human error. However, it was completely not a human error; rather the instruments were not able to perform accordingly. There were flaws in the instrument which ultimately misguided the pilots. A detailed analysis can be conducted on the entire scenario so as to understand the actual reasons behind such massive plane crash. It is clearly evident that there was some form of distraction which restricted pilots from integrating control inputs within specified time-frame. Adam Air Flight 574 basically crashed because the pilots were highly distracted because of some system failure.  The registered PK-KKW denoted a major failure in IRS. In the initial phase, the pilots were busy troubleshooting problems within the navigational system, thereby, cancelling all connections with autopilot controller. Once the connection with autopilot controller was disrupted, the pilots were unable to monitor the aircraft approaching the sea and finally crashing into it. When the aircraft was around 35,000 feet, it could not be traced under radar screens (Ionides, 2008).   Tatang Kurniadi, head of the National Transportation Safety Committee, clearly stated in a conference that the aircraft accident was due to multiple reasons occurring in a serial order.  It cannot be standardized that the aircraft crash took place due to one particular reason, rather consecutive failures, pilots’ distraction, etc. led to loss of control over the system. In the last two minutes, the flight instruments could not be properly monitored which resulted into discontinuation by the pilot. Instrument failure is one of the major causes behind majority of aircraft crashes. It can be argued that malfunctioning of navigation system ultimately distracts a pilot from performing their scheduled functions (Nugraha, 2016).   In such cases, it is commonly assumed that pilots were not properly trained to overcome problems while flying. On the contrary, it is even stated that communication problems between pilots and air traffic controller has caused such problems.  Arguably, a detailed review proved that the instrument failure resulted into series of miscommunication and irregularities in functioning. The bank angle got unnoticed and there was increasing descent due to IRS failure. Further information about the accident was also gained from the Cockpit Voice recorder. The recorded version clearly revealed that both the pilots were highly worried about the improper functioning of IRS (Perrow, 2011).  For around 13minutes, the pilots were engrossed into detecting IRS problems, rather than focusing on various other flight requirements. The entire scenario even encompassed attempts and identification at the most appropriate directions.  There was couple of statistics forwarded in context of the final moment anomalies. Arguably, communicated messages regarding abnormalities in functioning remained unattended. Some of the official investigators involved in the case even elaborated on the fact that disintegration of the aircraft was due to high speed impact. The aircraft had already undergone navigational problems since past many years (Moir and Seabridge, 2011).  This instrumental inefficiency was never seriously taken into consideration by the management. Similar navigational problem had already occurred with B737 in the year 2006. The flight could not be traced in radar screens for many hours and finally the pilots had decided for an emergency landing.  It has been detected there are approximately 154 defects within PK-KKW’s version. These defects usually remain unnoticed, resulting into serious damage. To a certain extent, the procedural error was the alert and other monitoring results being sent was not given consideration by the pilots, since they were busy with the navigational system. In general context, pilots are usually trained to place emphasis on every operational function, rather than considering only one malfunction (Herald & Times Group, 2017).   Another human error in this accident was lack of managerial interest in context of recovering the system from defects. The airline was not able to address their flaws due to financial incapability. Adam Air Flight 574 suffered from instrument failures which gradually resulted into a human error on pilot’s behalf. A collaborative approach would have prevented the instrument failure.


From the above study, it can be summarized that instrumental failures often create panic among pilots. They are unable to respond to such failures in the most appropriate way. Pilots could not respond at the right time because they were unable to respond to the signals being sent. The navigation system forms a major instrument in an aircraft machine. Pilots are highly dependent on navigation system while they are on flight. The main problem with Adam Air Flight 574 was a fault in their navigation system. In previous investigation reports, it was revealed that the pilots were distracted and failed to reflect upon signals. Arguably, the aircraft crash was completely not because of failure in considering transmitted signals. It can be claimed that pilot got distracted mainly because of instrument failure. To prevent aircraft crashes, it is important that the management should look into instrument failures, prior to allocating specific tasks to pilots. As witnessed in the case of Adam Air Flight 574, problems in the navigation system were detected since many years.

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