Indonesian 737 crash Pt1

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Pacific Historian
Jun 4, 2005
Orange County, CA
I saw this on another forum. It has to do with the operator of the 737, named "Adam Air".

I dont know if this can be considered shocking or funny.... Civil Aviation: Adam Air - The Flying Circus Nightmare

After the spectacular incident where PK-KKE went off course a few months ago, where it landed at some isolated small airport 400NM off away from its destination, many of us down here suspected bad maintenance as a cause. Despite all the press statements by Adam Air citing pilot error, the Directorate General of Air Communication (DGAC) placed an order for Adam Air to fix the IRS of PK-KKE (B733) and it would require 13 proving flights with the DGAC on board inspectors over a few months for PK-KKE to be released for unrestricted commercial flying.

Now, a quick look into Adam Air in the few months revealed some (not so) shocking discoveries, mainly around the commercial vs safety issues. All this culminated in the strike by the Flight Ops Officers at CGK station around 2 weeks ago, where they wanted better pay (they're amongst the lowest paid in the industry), and better safety, and the reemployment of 10 of their colleagues who were fired for "differences with management."

I have decided to write some of these up based on publicly available information, witnesses and also conversations with current and former Adam Air personnell, and many of whom wished this information to be known public but without fear of reprisals to their livelihoods, their lives, and also mine.

Does management understand the real meaning of the word "safety" ?
There are serious doubts as to the safety conscience of the senior management within the airline, in particular, the owners. The effects of the PK-KKE incident (Tambolaka Incident) did not dent Adam Air's image thanks to a quick hash up of the incident despite all the discoveries by the press regarding the handling. However, the management was quick to put the blame on the pilot and the first officer (who was a DGAC pilot attached to the airline). This resulted in Adam announcing that it was to place criminal charges on the two pilots for endangering people's lives (some sort of attempted manslaughter) through professional negligence. This yielded public protest from the pilot community and in particular Adam Air's pilots, who already had 17 colleagues being sued by Adam Air for not paying their bonds (20,000 USD).

Strangely enough, those 17 pilots that were being sued had in the past refused to fly aircraft that were not in a safe condition to carry passengers. The pilots were taken off the rosters and did not fly for some months, depriving them of income through per diem pay, flight hour pay and meal allowances which can form 25 - 40% of their income. When they decided to resign because the company wouldn't put them on flying duties, the company decided to sue them for their working bonds and other damages such as losses from training costs etc. Bear in mind that some of these pilots may already have had their type ratings before they joined Adam Air.

Further concerns of Adam Air's safety comes to the flight attendants. Adam Air's flight attendants often fly with maximum daily duty time and minimum rests at outstations, as well as being worked to the maximum legal limit of 6 days flying in a week. Fatigue have resulted in at least one known case of an Adam Air flight attendant being hospitalised for fatigue or illnesses where fatigue is a major contributory factor. The other side of the concern is the relative experience of the cabin crew on a particular flight. Adam Air is known to have put many junior flight attendants on a gruelling roster and place them as Pursers/CA1 within 6 months of flying duty.

Incidents, accidents, maintenance defects and deferrals

1. Tambolaka
The most well known of all Adam Air incidents is the Tambolaka Incident. The details of this incident have been discussed before in this forum. A few months down the road, it can be said that the company's handling of the Tambolaka incident was also hilarious and shocking.

The National Transportation Safety Committee (NTSC) ordered was appalled when their go-team was left stranded in Denpasar when they were due to fly to Tambolaka with the Adam Air engineers, after the flight they were supposed to take flew with the engineers but without them. The NTSC was then appalled that the item of focus for the investigation, PK-KKE's IRS, was "repaired" before they arrived. NTSC cited that this was an obstruction to the investigation and a deliberate attempt to hide evidence. The NTSC was further hindered in that the aircraft flew to Makassar after being repaired without the NTSC's prior approval. The DGAC also protested against such a move, but Adam Air insisted that the aircraft had permission to fly to Makassar immediately after it was repaired but would not state which DGAC officer gave the approval.

2. Weather Radars
During last monsoon season, one Adam Air pilot has once called me asking for weather satellite pictures of Indonesia. I had asked him why and his answer was shocking. "At one stage, all of our 732s had no weather radar." Despite this, they were forced to fly into the night in areas with dense cumulus and Cumulonimbus clouds that is prevalent during monsoon season.

3. A 737-3/4/5 flat battery incident.
A few weeks ago I received a message asking about the 737-3/4/5 electrics. Apparently, during cruise, the GEN2 have failed. Normally, the flight would continue with the APU GEN enganged to replace the failed GEN. Unfortunately, the plane had somehow been dispatched with a flat battery which wouldn't recharge. The aircraft continued to the destination on a single GEN and its unclear whether there was a nearer suitable airport to divert to as no further information was given.
Various incidents over the last 10 days:

4. PK-KKE (B733)
PK-KKE has been flying under DGAC surveillance since then until last week when it finally completed 13 flights without any IRS problems, although PK-KKE's story doesn't finish there, two days ago, PK-KKE's IRS#2 went unserviceable again and this time the crew decided to RTB and the crew refused to fly the aircraft. Passengers were left wondering why they returned and complained that they were already late. Adam Air's answer was "we left some of your last minute bag this time, and you should be on your way shortly," while they go and look for another crew to fly. It seems that this aircraft's IRS is a never ending saga.

5. PK-KKF (B732)
A year back, Adam's 732 pilots have protested to the management regarding its decision to delay the maintenance of PK-KKF due to a missing rear section of the leading edge slats on the right wing. Three pilots who have raised this issue with me personally have now left the company due to the management's handling of various safety matters.

Within the last 7 days, PK-KKF's left engine would not start in Semarang and the aircraft had to remain overnight there after spares had to be flown in and maintenance done overnight. Given that this is a long holiday weekend, it resulted in a huge mess throughout the Adam Air network.

This 737-200 had two incidents/defects over the past 10 days.

Last week, the aircraft was heard radio-ing Fatmawati Tower (Bengkulu airport) asking if a pushback truck was available at the airport. The airport had no pushback trucks, so the crew asked "which runway direction would give (him) the longest distance to the taxiway intersection (next to the apron). A witness then photographed why the aircraft asked for the information, it lost its HYD A pressure resulting in no nosewheel steering.

Instead of RTB-ing, the aircraft landed and stopped in the runway, blocking it, to drop its passengers and bags. Then, it was pushed back to apron using raw muscle power.

The problem was traced to a hydraulic rubber line that had hardened and the hose had split near a pipe joint. Adam's solution? Don't replace the line, save cost by cutting the split section and connect the shortened hose to the pipe and the aircraft is then dispatched.

This weekend, the aircraft again reported problem, the left fuel flow gauge was inoperative. After a short groundstop where the engineers "opened it up and cleaned it up", if flew again with the gauge now working. However, before the flight ended, the right fuel flow gauge became inoperative. The pilot suspected that they had just "swapped the gauges". That suspicion was blown away when today it flew and then both fuel flow gauges broke down.

9. PK-KKT (B733/4/5)
Four days ago, this aircraft had a single IRS unserviceable and one of the operations officer refused to sign off the aircraft for dispatch. The management forced the aircraft to fly because it was carrying "valuable cargo." Normally, the aircraft shouldn't fly, and even if it did, it is restricted as follows:
-a Remaining IRS operates normally and is used for both attidude indications and both HSI's AND
-b flight is restricted to DAY VMC
-c all standby instruments operate normally...
-d NO autopilot
-e Must not operate in RVSM airspace

It ended up flying to Medan in IFR with autopilot and in RVSM airspace.

Again on a on a flight to Medan, this aircraft's first officer panel went dead mid-flight. Calling maintenance, they were asked to see if the CB had popped up. To the crew's surprise, the CB did not pop out, it was split in two. The aircraft was stranded in Medan awaiting spare parts. A joke has quickly surfaced in Adam about KKT's panel, "when the right panel is dead, you can still use the left one!"

It is not clear if both of KKT's incident occured within the same flight, however, by the information received, it appears that occured on the same day.

10. PK-KKW (B734) and -KKC
On the 19th, PK-KKC went in for a C-Check, despite having an abnormally high-EGT problem resulting in the crew flying under reduced N1, the engine didn't go in for repairs at this opportunity. Instead, it was moved into PK-KKW, and continued to fly under N1 reduction until yesterday or two days ago when the engine gave up completely. The engine was repaired quickly at a cost of US$300,000. The humourous thing was, the aircraft today was put intensively to cater for Adam Air's 14 extra flights to Bali today, and one of the owners was quoted complaining today that "all those extra flights still can't cover that engine repair costs!"

11. Unknown, B732... oil pressure light illuminate inflight. No further details.

7 out of 11 of these incidents occured within the last 10 days. Staff in Adam Air have lost count on how many technical delays and incidents that had occured within that period of time. This number comes out of a fleet of around 18 - 20 aircraft.

Operational Policy and Safety Policy
It is apparent that some in the senior management has a serious lack of understanding of an aircraft's operating dynamics (that aircraft work in weights not volume), and the safety measures that prevails in the industry.

We all know that cargo is valuable, but it is not prudent to sacrifice safety for the sake of cargo revenue when you have paying passengers on board. If we look back at PK-KKT's incident, let's see how much they were getting.

On this 2 hr flight, the Take off weight was restricted due to the Maximum Landing Weight at the destination. It was carrying 2.8 tons of cargo. 2.8 tons of cargo would yield about US$9000, now if it wasn't full and was carrying only 150 pax, that would mean that the lives of each passenger is valued at US$60 thanks to Adam Air's policy. That's not worth much is it?

Cargo, Safety and Flight Ops - The daily conflicts.

One of the most dillematic part of Adam Air operations is the flight operations department. Due to various conflicts and poorer than industrial standard working conditions, the Adam Air Flight Operations Officers in Jakarta decided to strike on 11th of August, causing chaos on Adam Air's operations. By the end of the day, of all 46 FOOs, 33 were fired, and there was a huge gap in the FOO coverage.

Adam Air covered the deficit by "importing" FOOs from its outstations as well as newly recruited FOOs were put to run the show immediately. However, unlicensed FOOs also filled the gap. One case is a former company debt collector who was sent there to "help". The person has absolutely no clue on Civil Aviation Safety Regulations, weight limits, fuel requirements etc, let alone being licensed.

On the friday, Adam conducted interviews for FOO applicants and put them into use. All those previously rejected were immediately taken in. Even the former district manager of Bouraq and station manager of Jatayu was taken in.
Adam is still seeking ways to take legal actions against 33 FOOs they fired.

In Adam, the FOO is under Ramp and is supervised by the ramp manager. The ramp manager (which is not a licensed FOO) would not know what to decide when confronted with flight planning issues/problems especially when a conflict occurs between the FOO and the Cargo department. The FOOs measure the payload to conform to the performance limits. Explaining this to the cargo department or the ramp manager is a futile exercise because he does not understand why there is the Single Engine climb limit weight or why there is a V1 and a runway performance chart. What he does understand is the language of the cargo manager, which is "if there's space, why not fill it". The concept of weight limitations (instead of space limitations) seems like an alien concept to them, including the management.

This safety problem is further boosted by the management's emphasis on prioritising cargo. The Chief Pilot has no say, it is maximise cargo revenue to the limit, and cutting cost to the absolute minimum.

"It happens often..."
One sad example that is a result of this is on the 15th when over the radio it was heard that a 732 destined for PNK diverted due to low visibility. The Terminal Area Forecast was different from the actual, which was only 500m. The Flight Ops department could not get the actual weather of the destination. There is no telex, the photocopier had to be shared with other department (including sales and ticketing, who needs a LOT of photocopying). Where could the actual weather information be obtained from? No one is in the Adam Air office in PNK yet as it was too early in the morning. Upon hearing of the diversion, the Flight Ops in CGK was heard calling the aircraft to apologise and was replied, "It's OK, it happens often."
Bad habits are fuel for displeasure
The negative side effect of the Flight Ops being under Ramp is happening in the critical aspect of flying: FUEL. With the senior management wielding absolute power, it is normal for a displeased colleague to report any incident directly to the senior management to seek retribution in the form of punishment to the so-called offending party. With FlightOps being under Ramp, fuel uplift becomes a conflict of management hierarchy. An incident was reported by a witness where the ramp agent threatened to report the flight ops officer to the management because the agent had filled the tanks to 9,500kgs of fuel when the captain ordered 10,000. The fuel truck was unhappy to return only to pump 500kgs of fuel.

This was a result of "following habits" and not consulting with the flight-ops department as the necessary extra 500kgs of fuel due to heavier than normal headwinds to the destination. When the error was discovered, because the Flight-Ops is below Ramp, the ramp agent would throw his fits at the Flight Ops.

With the company's emphasis on cargo, and that the ramp agent is the one supervising the cargo loading, the risk of a ramp agent to under-report the cargo weight to the flight-ops is there.

Junior Flight Operations Officers tend to accomodate these conflicts, however, not so in the right way. One aircraft was 700kg over MZFW, the FOO told the pilot that he "overloaded the aircraft" by 700kgs. Not wanting to enter a delay to offload everything, the Captain asked, "So I'll just burn off the 700kgs before take off."So after pushback it sat there burning off the 700kgs (about 15 minutes worth to lower weight. When another flight ops officer not supervising the flight saw this, he asked the ramp agent why was it doing engine run ups after pushback. The reply was "he's over MZFW by 700kgs so he's there burning the 700kgs so he'll be legal for take off."

Where does this end?
This lack of understanding on MZFW also extends to the management who recently asked for all flights inbound to Jakarta Soekarno-Hatta Intl (CGK/WIII) to have file with Jakarta Halim Intl (HLP/WIHH) as an alternate, instead of the other alternates about 50 minutes away. Their reason for this is so that the airplanes can carry less fuel and carry more cargo instead. However, with all Adam Air flights having restricted take off weights due to Max Landing Weight limits or MZFW limits, this seriously cast a cloud of concern and fear that perhaps, until one of Adam Air's jets become a smoking hole in the ground, there will be no change.

What do you think?

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