NTSC Investigation of Boeing 737-4Q8 PK-KKW Accident in Makassar Strait

Overview of the Investigation Report The National Transportation Safety Committee (NTSC) of the Republic of Indonesia produced an aircraft accident investigation report identified as KNKT/07.01/08.01.36. The report concerns a Boeing 737-4Q8 with registration PK-KKW that was involved in an accident in the Makassar Strait, Sulawesi, Republic of Indonesia, on 1 January 2007. The NTSC is part of the Ministry of Transportation and published the report in 2008. ## Scope and Purpose The investigation was carried out in accordance with Annex 13 to the Convention on International Civil Aviation, Indonesian Law (UU No.15/1992), and Government Regulation (PP No.3/2001). The NTSC states that its investigations are conducted solely to enhance aviation safety. The report is therefore limited to matters of safety significance and is not intended to assign blame or liability. Readers are encouraged to copy or reprint the report for further distribution, provided that the NTSC is acknowledged as the source. ## Report Structure The report includes a synopsis, factual information, analysis, conclusions, safety action, safety recommendations, and appendices. Factual information covers the history of the flight, injuries to persons, damage to the aircraft, personnel information, aircraft information, meteorological information, aids to navigation, communications, aerodrome information, flight recorders, wreckage and impact information, medical and pathological information, fire, search and survival aspects, test and research, and organizational and management information. ## Organizational and Management Information The report includes sections on Adam SkyConnection Airlines (AdamAir) and the Directorate General Civil Aviation (DGCA) surveillance of AdamAir flight operations and airworthiness. Additional information addresses standby attitude indicator erection to false vertical, IRS transfer switch, electronic flight instrument transfer switch, mode selector unit, autopilot disengage, navigation system description, inertial system, IRS alignment, loss of alignment, navigation system assessment, flight management system, aircraft on ground, aircraft airborne, pilots’ flight track information, general information on Makassar Advanced Air Traffic Services (MAATS) air traffic control related issues, radar, and human factors. ## Conclusions and Safety Actions The conclusions section includes findings related to operations, maintenance engineering issues for AdamAir and the DGCA, and other findings, followed by causes and other causal factors. Safety action is directed to the Directorate General Civil Aviation, AdamAir maintenance, AdamAir operations, and Angkasa Pura I. Safety recommendations are addressed to the Directorate General Civil Aviation, Adam SkyConnection Airline, Adam Air and other Indonesian airlines operating Boeing 737 aircraft, the Ministry of Transportation of the Republic of Indonesia, and Angkasa Pura I.