Boeing 737-400 PK-KKW — Selat Makassar

Ensuring that the airline’s maintenance organization has appropriate procedures to ensure the serviceability of the complete IRS system; and

Aircraft upset recovery training; both ground school and simulator; and

The National Transportation Safety Committee (NTSC) recommends that Adam Air should review the effectiveness of its training for cockpit crews, specifically related to crew resource management, safety critical systems, and the appropriate use of standard operating procedures, including the Quick Reference Handbook.

The spatial disorientation and its effects.

Ensuring that the airline’s maintenance engineers are appropriately trained and qualified to trouble shoot IRS defects, other than simply changing the Inertial Reference Unit (IRU) and associated components, and cleaning connections

An INCERFA (uncertainty) phase is required to be declared when there is concern about the safety of an aircraft or its occupants when communication is not received, or the aircraft fails to arrive within 30 minutes of a prescribed time. The ALERFA (alert phase) is required to be declared when there is apprehension about the safety of an aircraft and its occupants when communication is not received...

Ensuring that Indonesian airlines’ maintenance organizations have appropriate procedures to ensure the serviceability of the complete IRS system.

DGCA to define radar calibration period

MAATS to have enough number of ATC personnel to meet the operation requirement (for each sector with one executive and one planner).

The regulator (DGCA) should ensure that the airline operator addresses the deep concern about the repetitive problems in the Inertial Reference System and ensure they take their best effort to minimise repetitive problems related to the aircraft navigation system

All operators to review their training and procedures to ensure that their pilots are trained to correctly perform the initialization of on-board Flight Management Systems

The ATC controller to reconfirm the aircraft position during transferring to other sector.

Ensuring that Indonesian airlines’ maintenance engineers are appropriately trained and qualified to trouble shoot IRS defects throughout the IRS system, other than simply changing the Inertial Reference Unit (IRU) and associated components, and cleaning connections

All operators to review the training and operational procedures, to ensure that their pilots are appropriately trained in severe weather recognition and avoidance, and that pilots be required to adhere strictly to the flight procedure of severe weather avoidance whenever severe weather is known or expected; and the pilot should continuously recognize their present position and should report the re...

Note the concerns expressed in paragraph 1.18.3 of the Preliminary Factual Aircraft Accident Report

MAATS personnel should be trained in accordance with ICAO standard and radar manufacture procedure which include MAATS procedure

The spatial disorientation and its effects.

The ATC controller to reconfirm when the target on the radar screen became as a flight plan track.

Immediately require an extensive inspection of the Adam Air fleet of aircraft.

Thoroughly review the adequacy and the implementation of the Adam Air maintenance program.

The regulator (DGCA) should review the airline operator’s training syllabus for cockpit crews, specifically related to Inertial Reference System, navigation system abnormalities.

MAATS to review the use of color (green) in the radar display to indicate at their authority (jurisdiction).

Aircraft upset recovery training; both ground school and simulator; and

The National Transportation Safety Committee (NTSC) recommends that the Ministry of Transportation review the related laws and procedures to ensure appropriate salvage capability is resourced and available without delay following an aviation accident requiring underwater aircraft wreckage recovery. In particular the laws and procedures should ensure the requirements of ICAO Annex 13 Paragraph 5.7...

DGCA to review the use of flight plan track display for controlling.

MAATS to do the recurrent training of ATC personnel in simulator every two up to three months for each ATC personnel (EUROCAT requirement).

MAATS to have operation procedure which shall be approved by DGCA