The Worst Airline in the World (Adam Air Flight 574) - DISASTER BREAKDOWN

Low-cost airlines are seemingly everywhere in the modern aviation market. Over the last 30 years, these low-budget operators have sprung up in all regions of the world, offering low fares and a basic A-to-B service. In the 2000s decade, massive low-cost expansion in Southeast Asia gave rise to many airlines based out of Indonesia. One such operator was Ademir. For a time in the mid-to-late 2000s, one could easily argue that Ademir was not only one of the worst airlines in Indonesia, but possibly one of the most unsafe in the entire world. Three hull losses and multiple other incidents occurred over a two-year period between 2006 and 2008, the deadliest of which transpired on New Year's Day of 2007. The disaster of Ademir certainly highlighted Indonesia's poor aviation safety record. The story is just as much about the airline marred in controversy, corruption and nepotism as it is about the disaster itself. Launching in 2003, Ademir was founded by two people. Indonesian businessman and politician Anggung Laksono, who was at the time the speaker in the Indonesian House of Representatives, and businesswoman Sandra Ang. Ang, originating from China, decided to name the new airline after her 26-year-old son Adam. While Sandra was the official owner of the airline, she appointed her son to the position of CEO. Other upper-level management positions were also filled by Ang's children and the son of Anggung Laksono, the other founder. Ademir was just one of many airlines in Indonesia that had begun operating around this time. The average price of an airline ticket in Indonesia had been plummeting, meaning more people from this developing nation could travel whereas they couldn't before. It also meant that more pilots in other airline positions needed to be filled as the market exploded. To stand out amongst the competition, Ademir was branded in a very informal, casual style. The planes were painted in a colourful orange livery. The airline was successful. In 2006, Ademir was the fastest growing airline in Indonesia. Like many low-cost carriers, they sought out older planes to make up their fleet. They operated four different models of the Boeing 737, from the 200 through to the 500 models. All of their aircraft were of varying age as the 200 models date back to the 1960s. The second generation Boeing 737 classic series of planes, that is the 300, 400 and 500 models, made up the majority of Ademir's fleet. It was once one of the most popular planes in the world. Being able to carry up to 168 passengers in a one-class configuration, the type was also very popular with low-cost carriers on the second-hand market. One plane that was leased to the company was a particular Boeing 737-400, registered as Papa Kilo, Kilo Kilo Whiskey. This plane first flew in 1989 and was first delivered to a long-defunct airline in the United Kingdom. After being acquired by British Airways, it had been transferred from airline to airline over the years, having performed over 26,000 flights by the time of the accident. It was only one of a few planes at Ademir which did not get the colourful makeover, branded in a mostly plain white livery. It would make its final flight on January 1st 2007, Ademir Flight 574 from Surabaya to Monado. The aircraft had already flown in from Jakarta earlier that morning, but would leave the city of Surabaya at 12.59pm. On board were 102 people. Up on the flight deck were the two pilots. 47-year-old Captain Referee Agustin Wododo was hired by Ademir in 2006. With over 13,000 flight hours to his flying career, he was a highly experienced pilot. His first officer was 36-year-old Yorga Susanto. He was much less experienced, but still had over 4,000 flight hours logged, over 1,000 of which were in the 737. One of the areas where Ademir clearly cut corners was in pilot training. What is interesting of note for what we will be discussing later, is that training in the complete failure of a particular navigation instrument had not been completed by either of the two pilots. This area of training was in relation to failures of the inertial reference system or IRS. We will come back to this later. Heading northeast that afternoon, the flight to Surabaya took around 2 hours and 15 minutes. The flight plan would take the 737 over the southern and central regions of the island of Sulawesi. The first half hour or so of the flight would appear to be normal. The pilots would notice though that things were going wrong over this stretch of the Java Sea. Just 15 minutes after taking off from Surabaya at 1.14, air traffic control in Yujung instructed the pilots to fly direct to a waypoint fixture named Deola. Deola sits on the Whiskey 32 airway which happens to run between Surabaya and Manado via Makassar in south Sulawesi, making for easy routing on this flight. The 737 cruised on autopilot at 35,000 feet. 30 minutes into the flight, the air traffic controller handling flight 574 would notice the plane was flying off course, exclaiming that they were flying north of the The pilots too also identified a navigational error themselves and determined that there was a fault with the IRS system. The IRS is an instrument which provides navigational information to various other aircraft systems such as the autopilot and flight computer. It needs to be aligned before the start of a flight to pinpoint the initial starting point of the plane. The IRS would then calculate where the plane moves and feed that information to the necessary outputs. Recorded data from the flight data recorder did show that the IRS system was aligned properly in Surabaya, but following the plane's departure, the IRS began feeding incorrect information to the plane in a way that flight 574 began drifting north of their intended flight path. In the months preceding the accident, pilots had complained about the IRS unit on this plane. It was never properly fixed by the airline. Apparently when pilots did complain, maintenance staff would swap the units from another aircraft and give the faulty unit a basic clean before being reinstalled until it eventually found its way onto the accident plane. It is unclear on what the fault with the IRS unit was exactly. It was never salvaged due to the expense needed to retrieve it. A faulty IRS unit alone however was not the sole cause for the loss of this plane. There is a lot more to this disaster. To delve deeper into this mystery, we need to progress further with the flight. What you are about to hear is the supposed recovered cockpit voice recording that was publicly leaked following the accident. You'll notice the controller's attempts to get the attention of the pilots in noticing that they had flown off course. The pilots of flight 574 had now flown into a thunderstorm. The kind that pilots would typically want to avoid with hail, severe turbulence, lightning and icing. Flight 574 flew right through it. The pilots were distracted by their faulty IRS unit. Here, the captain suggests changing the setting on the IRS unit to attitude mode, indicated on the switch as ATT. This mode only supplies attitude and heading information. If a pilot has trouble with their IRS in flight, they can select the ATT mode. Pilots would then need to input the heading manually, and to do this, they must keep the plane in level flight. As part of this ATT mode process, the primary flight display screens will temporarily enter a blank state. So what happened to the Adam Air flight when the pilots tried to do this? When the IRS mode is switched into ATT, it also disconnects the autopilot. The pilot flying is then trusted to keep the plane level. It is during this time that the instruments would have went blank. In the case of this accident, poor crew management played a critical role. Instead of one pilot troubleshooting the problem and the other flying the plane, both pilots were concerned with the faulty IRS, so neither pilot had their hands on the control wheel. It is also noted the lack of action the crew took to the autopilot disconnect alert. Now, this 737 was an aging plane. It had been in service for many years. Because of its age, it had a natural tendency to roll to the right. As the autopilot was in control of the plane prior to the IRS mode switch, it compensated for this natural roll as it was in control of the ailerons, control surfaces which control the plane's bank. Because the autopilot disconnected from the pilots changing the IRS mode to ATT, the plane itself then began banking. This is why it was important for one pilot to be handling the plane. Over the following seconds, the 737's bank to the right would increase. Soon after, the pilots would want to switch the IRS back into the nav mode, which feeds the autopilot with all its necessary information. Here, the bank angle alert can be heard. This indicates that the plane's bank had exceeded 35 degrees. Neither pilot had noticed this as their attitude artificial horizon indicator had temporarily blanked out. Because of the storm they were in, in the dense cloud layers, they also could not see any kind of natural horizon either. Things would appear to go from very bad to much worse, as the overspeed warning now sounds. You may also have now noticed from the recording the sound of the wind increasing as well. During this time, the plane was in a nosedive, spiraling towards the sea below. In an attempt to recover the plane, the pilots would make another mistake. In this situation, it would have been necessary to level the wings of the plane first before pulling the plane from its dive. Instead, they went straight for the pullback, exacerbating the dive. The pilots were suffering from spatial disorientation. Adamir, flight 574 broke up in flight before crashing into the Java Sea, leading to the deaths of all 102 people on board. The wreckage of the 737 laid at the bottom of the sea for seven to eight months. In that time, the airline, Adamir, refused to put forward any of the funds to salvage the wreckage or recover the bodies of the deceased. And when they did agree to fund the operation, it was only for a one-week period. The plane's two black boxes, however, were found and were brought to the surface and examined. Interviews were conducted with other Adamir pilots and it became apparent that the airline had failed in training in multiple areas of not only IRS system failures, but also in crew management. Another navigation failure occurred on an Adamir plane in 2006, where pilots had flown over 500 kilometres off course and had become lost. The airline had those pilots arrested on grounds of endangering passenger safety. Other pilots had come forward about other failings at the airline and some even resigned, citing the poor navigational systems. Adamir sued those pilots saying that they had not fulfilled their contracts. Corruption was rampant at Adamir. One of the co-founders, Angung Laksono, apparently did not actually invest any of his money in the airline, but rather used that money for political gains. The other founder and owner, Sandra Ang, was also accused of embezzlement, misappropriating company funds exceeding $200 million. She was later arrested and banned from leaving Indonesia. The disaster of Flight 574 was the catalyst for the Indonesian government in 2007 in putting 15 Indonesian airlines on a watch list that would see their operating licenses revoked if they couldn't improve their safety record in three months. Adamir was among them. Another hull loss occurred at Adamir just 51 days after Flight 574 crashed. Flight 172, a Boeing 737-300, had been written off after a hard landing in Surabaya. Another Adamir plane overran the runway at Batam in March 2008. That incident highlighted that Adamir staff were clearly not trained in evacuation procedures as passengers had to leave the plane without the emergency escape slides being deployed. Though these two incidents were non-fatal, the Indonesian government had had enough of Adamir and their license to operate was revoked and the airline ceased operating in June of 2008. Indonesia's poor aviation safety record was noticed internationally. The European Union notably banned all Indonesian airlines for a time from operating in Europe. This even included the national Indonesian carrier Garuda Indonesia. The ban has since been lifted as Indonesian air safety has improved. Hello everyone, thank you so much for watching. 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