On January 1, 2007, Adam Air Flight 574 was lost in the Makassar Strait after the pilots experienced problems with the faulty, onboard navigation system and never noticed that the plane was rolling to the right. By the time the pilots were fully aware of the situation, their corrective actions made the situation worse by causing the plane to spiral dive – almost completely inverted – into the ocean, killing all 102 people. The investigation revealed a history of safety problems at the leading Indonesian budget airline, Adam Air, and led to sweeping changes in Indonesia’s aviation system, including better pilot training and aircraft maintenance practices.
Adam Air Flight 574 Takes Off on New Year’s Day 2007 into Bad Weather
It’s the very first day of the new year in 2007 when 102 people board Adam Air Flight 574 in Surabaya, Indonesia, heading to Manado, Indonesia. Among the 102 people on board, we have two pilots, 4 cabin crew members, and 96 passengers comprised of 85 adults, 7 children and 4 infants.
Not only is the airport busy because of this festive holiday, but Indonesia itself has benefitted from a booming budget air travel industry. Adam Air was founded in 2002 by Agung Laksono, an Indonesian businessman and the Speaker of Indonesia's House of Representatives, and Sandra Ang. The airline was named after Sandra Ang's 26-year-old son Adam, who was named chief executive officer (CEO) of the airline.
According to an article in the Asia Times, in 2007, Adam Air was Indonesia's fastest-growing low-cost carrier. The airline referred to itself in its promotional materials as a "boutique" carrier, expanding from 5 million to 25 million passengers over the preceding seven years. Their presence helped to get more people in the air as they made flying more affordable for most people who would never had the chance to fly before. So, it is no secret why so many people boarded Adam Air Flight 574 on this very day in January.
The pilot-in-command for our flight is 47-year-old Captain Refri Agustian Widodo who joined Adam Air in 2006 and is hailed as a seasoned veteran, having logged more than 13,300 hours of flying time. As pilot-in-command of Boeing 737 aircraft, he also has more than 3,800 hours of experience. The first officer is 36-year-old Yoga Susanto who joined Adam Air in 2006 and has 4,200 total flying hours with almost 1,000 hours logged as a Boeing 737 first officer.
This time of year, the area is plagued with very bad thunderstorms, and in fact, storms are forecast during this voyage. As the weather changes from the dry season to the wet season at this time of year in that region, cumulonimbus clouds are common over Indonesia that could sometimes extend up to approximately 40,000 to 45,000 feet (or 13,700 m). The formation of these clouds can be followed by heavy rain, strong wind and strong updrafts, turbulence, and as a result may be followed by super cold-water droplets that ascend and descend in the form of hail.
But despite the storms in the area, Flight 574 takes off as scheduled and is soon sailing up towards its cruising altitude of 35,000 feet (or 10,700 m). As the plane approaches a storm system shortly after reaching cruising altitude, the flight begins to experience some slight turbulence.
Adam Air Flight 574 Veers off Course Shortly After Takeoff
And just a few moments later, the air traffic controller handling the flight notices something unusual and says to one of his coworkers, “Where is Adam direct to? My God, he is flying north!” What he sees on radar is indeed mysterious – the plane has drifted north of its assigned flight path and now is heading straight toward a violent storm.
Powerful winds batter the plane as they enter the storm, and the pilots instruct the passengers to fasten their seat belts in preparation for possible turbulence. But they have bigger problems to worry about right now than the storm – the pilots of Flight 574 are not sure where they are right now.
Not only are the pilots discussing their concerns about the weather, which is getting worse by the moment, but they are also discussing problems with the plane’s onboard navigation system, known as the Inertial Reference System (or IRS), and the fact that differences exist between the two units.
The IRS consists of two independent systems, one for each pilot, which measure pitch, roll, yaw, acceleration, heading, latitude, longitude, and a range of other attitude and position parameters. Each system has its own inertial reference unit (IRU) consisting of instruments that provide data to each pilot’s attitude indicator and displays. And right now, those units are saying two different things to the pilots about the plane’s position. One is right and one is wrong, and Captain Widodo and First Officer Susanto want to figure out where they are before considering a course correction through the storm.
Meanwhile, controllers, who notice that the plane is off course and communicated that with the pilots, work with the pilots to try and get Flight 574 back on track. Controllers provide instructions for the flight to navigate toward Diola, one of their waypoints on their route. First Officer Susanto confirms the instructions from control.
But even though they have been given a new heading, the pilots still have no idea where they are, and they are flying deeper and deeper into a powerful thunderstorm. Hail and wind are pounding the fuselage. The plane is experiencing heavy buffeting.
Adam Air Flight 574 Pilots Attempt to Fix Problem with Navigation System
Tension in the cockpit is rising as the situation seems to be getting worse. The pilots consult their manuals to see if there is a checklist that addresses this situation with the IRS. Meanwhile, as they flip through pages of manual, First Officer Susanto asks control to confirm their current position, which control does.
Captain Widodo wants to take back manual control of the plane from the flight computer. He asks First Officer Susanto to switch from navigation mode to attitude mode.
The autopilot then disconnects, and an alarm sounds in the cockpit. Many of the instruments on the First Officer’s panel in front of the pilots go blank. Distracted by the confusion of not having things like pitch or roll information, they do not notice that the plane has started to slightly roll to the right, banking at a dangerous angle. The bank angle increases through 35 degrees, causing a robotic voice to call out, “BANK ANGLE!” over and over.
Now obviously panicked by the bank angle warning, the Captain shouts, “Put it back on NAV again, put it back on NAV again!” - an instruction to switch from hand flying back to a mode where the plane is flown by the navigation system. The plane is now banking so far to the right that the wings began to lose lift, causing the nose to drop. A chime sounds to inform the pilots that they are leaving their assigned altitude of 35,000 feet and are entering into a steep descent.
Adam Air 574 Crashes After High-Speed Spiral Dive
Suddenly realizing the gravity of the situation, Captain Widodo grabs the control column and pulls back sharply. But instead of leveling off, the plane dives straight at the ground. Inside the passenger cabin, massive G-forces smash the passengers and crew into their seats as the plane hurtles into a terrifying inverted spiral dive, accelerating downwards at incredible speed. An overspeed warning fills the cockpit as they rocket through Mach 0.9.
First Officer Susanto screams “Pull up! Pull up! Pull up!”
But there is nothing they can do now. The plane is pulling 3.5 G’s at an airspeed of 490 knots (900 km/h), far beyond what it is designed to endure. Two loud thunks reverberate through the plane as the incredible aerodynamic forces rip off the horizontal stabilizer. The rate of descent reaches a heart stopping 53,000 feet (16,100 m) per minute.
With the pressure of the forces too much on the plane, it begins to disintegrate while still in air. In the cockpit is the deafening roar of wind. Everything on the plane stops recording as the plane screeches through 9,000 feet. Flight 574 disappears from radar.
The controller tries frantically to contact Flight 574, and after getting no response, he issues a distress phase for the flight as he feels with reasonable certainty that the aircraft and its passengers are in grave and imminent danger. And, he was indeed right.
Search for Flight 574 Stalls as Indonesian Government and Adam Air Battle Over Costs
The search for the plane immediately encounters massive challenges. Based on the last recorded radar position, it was unclear if the plane had crashed into jungle or the sea, which meant that for weeks, searchers had to comb through both.
Another challenge arose when reports came out that the plane had crashed in the mountains with survivors, and the Indonesian government chose to publish that information before they verified it – there never was a crash site in the mountains. This also means that the families went through all that hope only to find there was no crash site in the mountains.
But ten days after the flight disappeared from radar, wreckage from what was Flight 574 finally made its way to shore, indicating that the plane had crashed while over the sea. Searchers eventually locate the wreckage at the bottom of the sea, finally confirming that all 102 people onboard perished in the crash.
Investigators must now facilitate the recovery of the plane’s black boxes, which are pinging from 2,000 meters (or 6500 feet) under the sea.
At the time, no sea vessel existed in SE Asia that could make a recovery from that deep of water. So, the Indonesian government knew it had to pay another country to bring in a vessel with these capabilities. And the government assumed that Adam Air would pay for it, but shockingly, the airline refused to do so. For seven long months, negotiations stalled, and no progress was made in the retrieval.
This meant that families had to wait while they quibbled over who was going to pay. It also meant that the black boxes remained submerged.
Eventually, the government and the airline make an agreement, with Adam Air agreeing to put up half the cost of one week of searching. Faced with this stingy offer or no offer at all, the Indonesian government agreed, and a vessel ultimately retrieved the boxes while the wreckage is left at the bottom of the sea.
Adam Air 574 Investigation Rules Out Navigation Error, Weather as Cause
Meanwhile Indonesia’s NTSC (national transportation safety committee) prepares to investigate the crash. And, since the plane is a US-made Boeing, a team from the US’s NTSB joins the investigation. Thankfully, despite damage and a long time under water, both black boxes have data that is retrievable.
When investigators listen to the cockpit voice recorder (or CVR), it tells them the flight crew knew immediately that the IRS was sending them off course and that the pilots were very focused on trying to fix that problem.
Investigators want to make sure that the proper coordinates were entered into the navigation system from the start, and that this type of error had no impact on the crash. Usually, these coordinates are entered into the navigation system by the flight crew while the plane is still at the gate. Investigators find that the coordinates were indeed entered correctly, as confirmed by the flight data recorder (or FDR), so that is not the issue. We explored another story where a plane veered off course, in episode 61, Korean Air Flight 007. In that crash, investigators deduce that the pilots either mis-keyed a waypoint, which put them on the incorrect course, they forgot to turn the INS to on, or the INS was activated by the pilots but was not functioning properly. Without data from the aircraft, investigators can only offer these reasons as to how the plane veered off course.
And amazingly, the storm itself played no direct role in the crash. It certainly did not make things easier as the presence of the storm made it hard for the pilots to see the horizon – everything would have looked gray and cloudy all around them.
Adam Air Flight 574 Investigation Reveals Poor Maintenance Practices
But just as the flight got airborne, investigators can tell from the FDR that the IRS sent the flight off course almost immediately. When investigators look at the maintenance records for this plane’s IRS, they find something disturbing. For over three months, pilots had been reporting problems with the IRS, mostly that the two units disagreed about the lateral position of the airplane, indicating that one of them was faulty. It did not appear that maintenance had managed to get to the root of the problem. The unit was never taken out of the plane and sent for repairs, which is what should have happened. Maintenance would only clean the unit every time a complaint cropped up.
It is clear from what investigators know about the crash so far that problems with the IRS caused the plane to veer off course, but it was not the only factor in the cause of the crash.
Based on the data from the CVR and the FDR, the investigative team creates a simulation of the flight – this will show them everything the crew said and did.
Adam Air 574 Pilots Experienced Spatial Disorientation
Captain Widodo wanted to take back manual control of the plane, so he asked the First Officer to switch the plane from navigation mode to attitude mode. Switching an IRS to attitude mode causes the IRS to reboot, and as it does, it has to go through an alignment process where it determines which way is up, which way is down, and which way the plane is moving. During this time, a few things happen automatically – first, the flight displays for that unit will go temporarily blank (which they did) and the autopilot will disconnect (which it did).
The procedure advised that after flipping the switch, the pilots would simply need to hold the plane straight and level for 30 seconds while the system reboots. But since the displays go blank for half a minute, it also takes away the attitude indicator (or ADI), which tells them if the plane is flying level. And we know that it wasn’t – it tended to pull toward the right. And that’s when the plane began to roll about 1 degree per second.
As we mentioned, the autopilot also disconnects automatically during this recalibration, but they seemed to not notice that the autopilot was off. Because this plane had a tendency to roll to the right, the autopilot controlled the plane and kept it level by raising the right aileron, which controls the plane rolling to the right or left. But with the autopilot off and their displays blank, the pilots did not notice the plane was banking until the alarm sounded.
Once the bank angle sounded, Captain Widodo did level the plane, but then he turned his attention right back to the navigation system. And this is the next critical mistake, the pilots should have divided and conquered – one pilot focusing on the navigation issue and one flying the plane.
Plowing onward through the clouds, surrounded by howling wind and driving rain, the pilots continued to fight with the IRS. Captain Widodo made a couple of small inputs to try to level the plane but never seemed to grasp the fact that they were continuously turning to the right. The first officer’s IRS failed to align because they were in a turn, and his instruments didn’t come back after 30 seconds.
Investigators also can see that when the Captain takes control back, he makes things worse. He should have leveled the wings, but because they were in a right turn and he pulled back, this move put his plane into a right spiral dive. The plane inverted and darted to the ground almost at the speed of sound. At this rate of speed, the only thing left on the CVR is the sound of the plane breaking itself apart as it races toward slamming into the sea.
It’s a classic case of spatial disorientation coupled with a plane that tended to roll to the right and a faulty navigation system all coming together to create a terrible, perfect storm. Investigators know that the pilots could have recovered at multiple points. The more significant failures in this sequence of events were the humans.
We’ve talked about similar situations in other stories. We highlighted a classic case of spatial disorientation in episode 17, the crash of JFK, Jr. We also talked about how a preoccupied flight crew failed to notice that the autopilot switched off and the plane rolled to one side, ultimately causing the plane to crash, in episode 55, Aeroperu Flight 603.
Adam Air Flight 574 Crash Reveals History of Poor Training, Safety Problems at Airline
The crash of Adam Air 574 raised questions about the entire Indonesian aviation industry. From an investigative standpoint, all eyes are on Adam Air. Investigators interview pilots from the airline and examine training on recovery techniques and IRS troubleshooting.
Investigators could not find any evidence that either pilot was properly trained on many of the most crucial aspects that contributed to this crash.
One of the first things they noticed was that Adam Air had given all its pilots copies of the operations manual downloaded from myboeingfleet.com, which were explicitly marked as not for operational use. They then found that Adam Air had not trained its pilots how to respond to failures of the IRS, or indeed almost any other automated system. They weren’t trained on how to react to an unexpected autopilot disconnect warning. And they hadn’t received upset recovery training, a standard module at major Western airlines, which among many other techniques teaches pilots to roll wings level before pulling up when in an inverted position. In all respects, the pilots were woefully unprepared for the situation they encountered.
Investigators ultimately point toward an airline plagued by systemic safety issues.
Adam Air Plagued by Safety Issues Before Crash of Flight 574
Adam Air had been involved in talks with multiple private investors, including discussions about the sale of a 20% stake to Qantas, a takeover bid from a private equity fund, and a planned initial public offering in Singapore. However, foreign investment interest evaporated with the crash of Flight 574.
Adam Air's safety record, like a number of other Indonesian airlines, had been heavily criticized. Pilots had reported repeated and deliberate breaches of international safety regulations due to the airline's attitude towards them and aircraft being flown in non-airworthy states for months at a time.
Seventeen of the carrier's 150 pilots resigned in May 2005 over their joint concerns about aircraft safety. Upon leaving the airline, they publicly complained about several incidents where they disagreed with management about the readiness of certain aircraft. They said that there had been such incidents as:
- Requests to sign documents to allow an aircraft to fly, while not having the authority to do so or knowing that the plane was not airworthy (or both),
- Flying one plane with a damaged door handle and another with a damaged window for months,
- Swapping parts between planes to avoid mandatory replacement deadlines,
- Being ordered to fly after exceeding the take-off limit of five times per pilot per day,
- Using spare parts from other planes to attempt to keep planes in the air, and
- Ignoring pilots' requests to abort takeoff, even though the planes were obviously unsafe.
In the Aisa Times, former Adam Air pilots gave a series of press interviews accusing senior management of putting profits before safety. One pilot reported that one of Adam Air's owners telephoned him with a direct order to fly an aircraft to Padang in West Sumatra despite the pilot's voiced concerns about a malfunctioning navigational backup system. This same pilot also claimed that on another occasion he was coerced into signing an aircraft-maintenance log without a mandatory check by engineers before a scheduled two-hour flight from Jakarta to Medan.
Another pilot said that he was grounded for a week by senior management over his refusal to fly after he had exceeded the regulation limiting pilots to five daily takeoffs. Many believed, and not without reason, that Adam Air got away with all its blatant regulatory violations because its co-founder was also the Speaker of Indonesia’s House of Representatives.
Then in 2008, another Adam Air accident happened where the plane slid across the runway. And that was the final straw that broke the camel’s back. On 18 June 2008, the Indonesian government definitively revoked Adam Air's operator certificate, and the airline ceased operations.
Adam Air Flight 574 Crash Led to Sweeping Changes in Indonesian Aviation
An important legacy in the crash of Flight 574 is that the Indonesian government now has a safety rating system for all carriers and implemented other safety reforms across the airline industry.
But some experts say these moves are not enough and that cost-cutting measures still are putting the public at risk. In the 2000s there were more than a dozen serious incidents and several major disasters.
For 10 years, Indonesia's flights were closely monitored by the International Civil Aviation Organization (ICAO) and the US Federal Aviation Administration (FAA). The European Union (EU) banned Indonesian airlines from operating there between 2007 and 2018.
Just as the industry emerged from the decade of sanctions and was getting ready to soar, COVID-19 struck and put financial as well as operational pressure on the airlines. The latest crash in that region happened when Sriwijaya Air Flight 182 crashed into the ocean shortly after takeoff on January 9, 2021.
A preliminary investigation into that crash found that a difference in the level of thrust between the plane’s two engines may have contributed to the aircraft rolling over before it plunged into the Java Sea. The investigation into that crash is still ongoing as of the date of this recording.