Investigation Summary
The investigation revealed a history of unresolved maintenance issues regarding the aircraft's Inertial Reference System (IRS), with 154 discrepancies recorded in the months prior to the crash. On the accident flight, the crew noticed a mismatch between the two IRS units. While attempting to troubleshoot by switching the right IRS to 'Attitude' mode, the autopilot disengaged—a standard system behavior the crew failed to notice or manage. Preoccupied with the navigation instruments, neither pilot monitored the flight path as the aircraft slowly rolled to the right. By the time a 'BANK ANGLE' warning sounded, the aircraft was in a 35-degree bank. The pilots' subsequent recovery attempts were inappropriate; they pulled back on the yoke while still in a steep bank, which tightened the spiral and increased G-loading, leading to an in-flight breakup at Mach 0.926.
Final Conclusions
The NTSC concluded the accident was caused by a combination of pilot preoccupation with a technical failure and a lack of situational awareness. The crew failed to fly the airplane while troubleshooting, leading to spatial disorientation and an upset. Contributing factors included inadequate pilot training on upset recovery and the airline's failure to rectify long-standing maintenance defects in the navigation system.
Video Analysis
What happened to Adam Air 574 — Experience the gripping story of Adam Air Flight 574, a tragedy marked by navigation failures, storm chaos, and critical mistakes. Explore the role of the Inertial Reference System, black box recovery efforts, and aviation safety reforms in uncovering the truth
Watch on YouTube ↗If playback is blocked, the owner has disabled embedding — use the link above.
Systems & Failure Modes
Inertial Reference System (IRS)
A navigation aid that provides attitude, velocity, and navigation data. Its failure and the crew's subsequent fixation on it were central to the crash.
Autopilot
Automatically disengaged when the IRS mode was changed to 'Attitude' (ATT), which the crew failed to recognize.
Bank Angle Warning
An aural alert that triggered when the aircraft exceeded 35 degrees of bank, providing the first clear indication of the upset.
Interesting Facts
- 01The aircraft impacted the water at nearly the speed of sound (490 knots calibrated airspeed).
- 02The flight recorders were recovered from a depth of approximately 2,000 meters.
- 03The IRS system on PK-KKW had been reported as faulty 154 times between October and December 2006.
- 04The aircraft was 18 years old at the time of the accident, having first flown in 1989.
- 05All 102 people on board, including 96 passengers and 6 crew members, perished.
Safety Actions & Advisories
Regulatory Reform
The Indonesian DGCA increased surveillance of airline maintenance and flight operations, leading to the eventual revocation of Adam Air's Air Operator Certificate.
Pilot Training Enhancement
Recommendations were made to improve pilot training in Crew Resource Management (CRM) and upset recovery techniques, specifically focusing on 'fly the airplane first' protocols.
Maintenance Oversight
New requirements were established for tracking and resolving repetitive defects in critical flight systems like the IRS.