Mayday (2013) s07e07 Episode Script
Flight 574: Lost
Where's Adam direct to? My God.
He's flying north.
NARRATOR: A Boeing 737 is badly off course.
(THUNDER CRASHES) Adam 574, confirm our position, please.
The crew struggles to get the plane back on track.
This is crazy! They're lost in a violent storm.
When their plane starts rolling over - Pull up! - COMPUTERISED VOICE: Pull up.
Pull up! (SCREAMING) The lives of 102 people are at risk.
Adam 574, Yu Jung, Control.
Then, mysteriously, Adam Air Flight 574 disappears without a trace.
January 1, 2007.
Surabaya, Indonesia.
It's New Year's Day.
There are celebrations throughout the country.
Surabaya's airport is bustling .
.
and not just because of the holidays.
Indonesia is experiencing a boom of budget airlines.
One of those new airlines is Adam Air.
Good afternoon, Departure.
This is Adam 574.
Adam, 574.
This is Ground Control.
Go ahead.
Adam Air was successful because it provided a fresh image to the industry.
They came in with bright colours.
Their airplanes were painted a fantastic orange.
The crew was, you know, flashy uniform.
They had everything right going for them.
Captain Refri Widodo has been flying with Adam Air for six months.
Today he's in command of Flight 574, a short domestic flight.
His copilot, Yoga Susanto, has been with the airline for almost a year and a half.
(BABY CRIES) There are 96 passengers and six crew members on today's flight.
Controllers at the airport are busy juggling planes.
(SPEAKS INDISTINCTLY) Adam 574 is clear for take-off.
- 80 knots.
- Check.
Rotate.
Today's flight is a routine two-hour hop.
From Surabaya on the island of Java to Manado on the island of Sulawesi, almost 1,700 kilometres north-east.
It's the beginning of the rainy season.
Weather is unpredictable.
Forecasters are expecting fierce storms.
Captain Widodo is aware that there may be bad weather ahead.
COMPUTERISED VOICE: Turn right, direct to FANDO, and climb to flight level 330.
Roger.
Turn right.
Direct to FANDO and climb to flight level 330.
Adam 574.
Minutes after take-off, the crew turns on the autopilot.
The flight computer will fly the plane and navigate it along a preplanned route Manado.
(BABY CRIES) Now passing flight level 220, climbing to flight level 330.
Roger, Adam 574.
Track direct to DIOLA.
Confirmed.
Tracking direct to DIOLA.
Adam 574.
Less than half an hour into the flight, air traffic controllers notice something out of the ordinary.
Where's Adam direct to? My God.
He's flying north.
Flight 574 has flown off course and is now heading into a violent storm.
Air traffic controllers don't know why.
Yes.
Mm-hm.
On board the plane, the pilots try to understand how far they have drifted off course The IRS.
28 is the difference.
.
.
and try to fix the problem with a computerised system that handles navigation.
May I have your attention? This is your captain speaking.
We are about to experience some turbulence.
(CRIES) Could all the passengers return to their seats? Controllers on the ground try to get Flight 574 back on course, giving them directions to their next assigned waypoint called DIOLA.
Adam Air 574, maintain 350.
Direct to DIOLA.
Confirmed, flight level 350.
Direct to DIOLA, Adam 574.
But to get there, Flight 574 must pass through a severe storm.
137km/h winds beat on the plane's hull.
It's pounded by hail and rain.
The crew is not just concerned with the weather.
They're still also trying to understand the problem with the plane's navigation system.
This is messed up.
Getting lost over the ocean is everyone's worry because when you lose your navigational instruments or you lose trust of your navigational instruments, what do you do? Copilot Susanto consults the aircraft's handbook.
It's starting to fly like a bamboo ship.
Captain Widodo doesn't know where he is.
- He needs directions.
- Confirm our position.
Adam 574.
Confirm our position, please.
Roger, Adam 574.
Position is 125 miles.
Mike Kilo Sierra.
Crossing radio 307.
Mike Kilo Sierra.
The weather in Mike Kilo Sierra isn't good.
The storm is growing worse.
This is crazy! We're going to get lost if it stays like this.
Captain Widodo wants to take over navigation of the plane from the flight computer.
OK.
Put the IRS in altitude.
But suddenly a warning.
(ELECTRONIC BEEPING) The autopilot has disengaged completely.
Then many of Susanto's computerised instruments go blank.
The crew doesn't notice that their plane is rolling over.
Flight 574 is banking at a dangerous angle.
Enough of this! COMPUTERISED VOICE: Bank angle.
Bank angle.
Bank angle.
If it rolls too far over, it could send the plane and the 102 people on board into a fatal downward spiral.
(SCREAMING) OK.
Put it back on navigate.
Put it back on navigate! Yes.
Put it on navigate! Captain Widodo wants to re-engage the flight computer's navigation system.
(SCREAMING) The plane is still rolling, and now its nose has started to point downward.
(SCREAMING) COMPUTERISED VOICE: Sink rate.
Another alarm tells the pilots that they are entering a steep descent.
Pull up.
Don't turn it! This is a headache.
- Pull up! - Pull up.
- Pull up! (SHOUTS) - Pull up.
Adam 574, Yu Jung, Control.
Adam 574, Yu Jung, Control.
Adam 574, radar service terminated.
Please contact Yu Jung, Control at 128.
1.
Inexplicably, Flight 574 has disappeared.
News of Adam Air Flight 574's disappearance spreads quickly.
The Indonesian Government starts mobilising search and rescue teams to find it.
Indonesia's National Transportation Safety Committee, or NTSC, is also notified.
The NTSC is responsible for finding out what went wrong in any plane crash.
Frans Wenas is in charge of investigating Adam Air 574.
The first steps that we take when there was an accident or serious incident We will find all the resources that we have and get the team together before we despatch to the area.
Working with air traffic control, the searchers try to pinpoint the last recorded location of Flight 574 .
.
about halfway through its intended journey.
OK.
So, right around here.
But the plane could have flown hundreds of kilometres after that signal was received.
It's impossible to pinpoint the exact location.
Without a specific location, searchers try to figure out how large an area to scan.
Since they know how much fuel was on board, investigators can calculate how far the plane could have flown since it was last detected.
If this is their last radar hit, they didn't have enough fuel to fly any further than this.
More than 3,000 people are sent out to look for the plane.
The Indonesians are joined by a US Navy vessel.
But the area they have to search is the size of Ireland.
The teams don't even know whether to look on land or on water.
And as long as there was no definitive word, hope remained.
12 hours pass without any confirmed sightings.
And then friends' and relatives' hopes are raised with news that survivors have been found.
Rescue teams hurry to the island of Sulawesi, hoping to return survivors to their families.
But when the first officials get there, they find that these survivors are not from the flight at all.
So they were ferry survivors, not airplane survivors.
They're from a ship that sank in another storm near where Flight 574 is thought to have crashed.
Now the rescue teams are back to square one.
It let people's hopes up.
And people flocked to Makassar, and they were finding ways how to get to the crash site only to find that it's not there.
For family members, it's a bitter disappointment.
(SPEAKS INDONESIAN LANGUAGE) TRANSLATOR: We were ashamed because the information was already spread all over before we verified it.
Our government was embarrassed that we publicised that information.
It's been a week since the crash.
(SPEAKS INDISTINCTLY) With each passing day, the chance of finding any survivors grows smaller.
There was still no clear picture of exactly where the plane had crashed and how it had gone down and why it had gone down.
Wenas needs to locate the wreckage as soon as possible.
Most of all, he needs the two black boxes that record conversations in the cockpit and flight data.
There are beacons attached to the boxes, but they only have a 30-day battery life.
Nine days after the crash of Adam Air Flight 574, a fisherman finds what he thinks might be part of an airplane 300 metres off the coast of Sulawesi.
The piece is taken to an Indonesian air force base for analysis.
Frans Wenas quickly identifies that it is part of a right elevator.
He examines it to see if it belongs to Adam Air Flight 574.
We checked with the serial numbers, we checked with the part numbers.
The numbers match.
So we are definitely sure that it is from the aircraft.
The finding confirms that Flight 574 crashed at sea.
The team can now narrow down its search to the area where the elevator was found.
Since the accident involves an American-made plane, the US National Transportation Safety Board joins the investigation .
.
and they send structural engineer Clint Crookshanks to Indonesia.
We started working with the NTSC to look at radar data, air traffic transmissions, weather data - trying to bring all that information together to find the airplane.
The water that investigators plan to search for wreckage is 6,500ft deep, much too deep to send down divers.
It was quite deep water, deeper than we're normally used to recovering airplanes from.
The Indonesian Government wants Adam Air to pay for the salvage operation.
Investigators meet with representatives of the airline.
It is going to be expensive.
We need to hire contractors to go down that far.
Adam Air felt that its responsibility only went so far.
The Government and most of public opinion believed that Adam Air's responsibility was actually almost total because they were the owners of the airline.
The airline refuses to pay for the salvage, triggering a lengthy negotiation.
This is not good news for Frans Wenas.
Unless someone puts up the money to search the seabed for wreckage, the mystery of Flight 574 will not be solved.
It is also a blow to the families of the victims.
The families obviously wanted to know what had happened to their loved ones, and they did want the Government and Adam Air to combine to get the flight data recorders out of the water.
As the investigation stalls, public anger grows.
People were becoming more and more critical of Adam Air and the way it was being run But then, after seven months of negotiating This is good news.
Thank you.
.
.
Adam Air agrees to help pay for the salvage.
Phoenix International, an American company specialising in deepwater salvage, starts the operation on August 24.
But the time they've lost has had a serious consequence.
Although they have a fix on the location of the crash, the locator beacons attached to the black boxes have gone dead.
Without the beacon, finding two small boxes among the wreckage will be a huge challenge.
To make matters worse, Adam Air has only put up enough money for one week of searching.
So it was like, "Go out there.
"If you don't find anything in seven days, you're done.
" After locating debris with sonar, an unmanned remote-controlled submarine is sent down to look for the black boxes.
Alright.
How are we doing? We dove on one location first.
We got to that GPS location.
There was nothing there.
Pull up quadrant 3.
So we sat down and decided we'd do a grid search about that point, and so we did a very methodical search.
OK.
Three degrees.
Alright.
Slow.
Slow.
We're coming up on something.
We started picking up small, lightweight pieces of airplane wreckage - things like life vests, seat trays, light bits of metal.
Oh, my God.
This is it.
Investigators get their first look at the wreckage.
This plane is ripped apart.
The state of the wreckage illustrates just how violent this plane crash was.
The little pieces of wreckage didn't tell us anything about the cause of the crash.
They did tell us, however, that the airplane hit the water at a very high rate of speed.
This was the most fragmented airplane that I have ever seen.
Only two days into the operation, Crookshanks spots something.
Alright, stop.
Rotate back five degrees.
I noticed on the left side of the video screen something that appeared to be orange, and I instructed the ROV operator to take a closer look at it.
That's it.
That'sthat's it.
OK.
Once we got over there, we realised that this, in fact, was the FDR.
We were very excited that we had seen and recovered one of the boxes.
Investigators soon find the cockpit voice recorder nearby.
Alright.
Stop! That's it.
Their week is up.
The salvage operation is over.
Investigators now hope that they have all the clues they need to solve this accident.
The black box is the only source for the evidence that we have because we don't have the wreckage, we don't have the witnesses.
But the boxes have been lying on the bottom of the sea for almost eight months.
They could be damaged beyond repair.
They may not yield any information at all.
The black boxes from Adam Air Flight 574 are taken to the National Transportation Safety Board in Washington, DC.
Investigators think the labs there are the best bet at salvaging any possible information.
CROOKSHANKS: If an FDR is found in salt water, it needs to be washed in fresh water and then contained in water the entire time until it makes it to our lab.
Salt and air together create a chemical reaction that results in rust.
The rust can damage the electronic components in the recorders.
Keeping them submerged in fresh water delays that reaction.
Frans Wenas also makes the trip to the United States.
We thought there might be an issue in recovering the data.
It wasn't as damaged as many others we've seen, so we were fairly confident if there was data recorded we would be able to get the data off of it.
Technicians begin the painstaking process of retrieving the information.
The job is a multinational effort.
MAN: The Australian Transport Safety Bureau was requested to assist.
We have an excellent relationship with the NTSB folk, and so our flight recorder specialist went to the United States and worked alongside the NTSB.
The electronic components containing the data are carefully removed and dried.
Then the information is uploaded onto a computer.
As the delicate procedure of recovering the data from both recorders progresses .
.
investigators are aware that they have an additional concern.
CROOKSHANKS: One problem that we ran up against in this investigation is the maintenance records indicated that the flight data recorder was written up as being inoperable in the weeks prior to the crash.
We were concerned with that, in that if we found the FDR, it may not have recorded anything.
Investigators keep their fingers crossed.
We've got it all.
It's all there.
I was confident once we found out that we had 100% of the data that we would be able to solve this accident.
The two black boxes provide investigators with the first solid clues about why Flight 574 fell from the sky.
SUSANTO: (ON RECORDING) Good afternoon, Departure.
This is Adam 574.
Now passing flight level 220.
Climbing to flight level 330.
Roger, Adam 574.
Track direct to DIOLA.
Confirmed.
Tracking direct to DIOLA.
Adam 574.
The conversation in the cockpit tells investigators that the crew knew that the plane's navigation system was sending them off course The IRS.
28 is the difference.
They're drifting.
.
.
and that they were preoccupied with fixing that problem.
This is messed up.
Where's Adam direct to? My God.
He's flying north.
Adam Air 574, maintain 350 direct to DIOLA.
Confirm flight level 350 direct to DIOLA, Adam 574.
To get from one waypoint to the next, the flight computer always has to know the plane's exact location.
That information comes from a component called the IRS or Inertial Reference System.
It tracks every adjustment to the plane's course to calculate its exact position.
It then feeds that information to the autopilot.
The autopilot needs to know where the aircraft is and where it needs to go.
The autopilot takes those data from the IRS in terms of height, heading and speed.
But for the system to keep track of the plane's heading, it has to know where the plane started.
The IRS has to be calibrated before take-off.
Usually the crew will enter the coordinates of the gate as the starting point for the computer to track.
Investigators wonder if the IRS guided the plane off course because the wrong initial coordinates were entered.
We just got this.
They check this by looking at information from the flight data recorder.
The numbers are fine when they're on the ground.
Yes, yes.
The data confirms the IRS was calibrated before Adam Air Flight 547 took off.
- This is where it begins.
- That's right.
But for some reason, the IRS began to send the plane off course almost as soon as the flight got in the air.
It just gets worse and worse.
I have something else I'd like to show you.
Some maintenance logs.
Crookshanks and Wenas look at the maintenance history of the IRS system that was on board Flight 574.
As you can tell, there's more than 100 write-ups here.
Look at this.
Same unit.
- Same problem.
- That's right.
The history shows that there had been numerous complaints about the plane's navigation system over the past three months.
Again and again.
Investigators wonder why the airline didn't fix the problem.
In the case of the IRS of this aircraft, that unit should have been taken out and sent to Maintenance for calibration or repairs.
Investigators discover that when pilots complained about a faulty IRS unit, the airline didn't fix it properly.
They would either swap it with a unit from another plane .
.
or often they would only do a basic cleaning of the malfunctioning unit.
MAN: They'd just pull up the connectors, spray it with some lubricant cleaners then put it back on, did some ground test and then just put "ground test OK" on the maintenance log.
Since the IRS is such a vital piece of equipment, this is contrary to all recommended repair policies.
Investigators listen to the cockpit voice recorder, hoping to discover how the malfunctioning IRS contributed to the crash.
This is crazy! We're going to get lost if it stays like this.
Don't turn it.
This is our heading! - Pull up, pull up! - COMPUTERISED VOICE: Pull up.
If you have a failure in one system, it shouldn't cause an accident.
Nothing they hear leads them to believe that an IRS malfunction alone could have caused the plane to crash.
Investigators now wonder if the severe storm Flight 574 flew into somehow played a role in this crash.
This is messed up.
This is really messed up.
It's starting to fly like a bamboo ship.
Let's confirm our position.
In order to determine if weather was a factor in the Adam Air crash, investigators need a more complete picture of what happened on board the flight.
They want to know everything the crew did and said from the time they discovered that they were off course to the time they hit the water.
To do this, they combine the data from the two black boxes to create a computer simulation of the flight.
Investigators return to Jakarta to study the simulation.
The weather in Mike Kilo Sierra isn't good.
This is crazy! We're going to get lost if it stays like this.
The can see that throughout most of the flight, the computer was navigating the plane.
But since the flight computer was sending the plane off course Position, please.
.
.
the captain decided to navigate the plane himself.
OK, put the IRS in altitude.
Copilot Susanto switched the navigation system to a mode that would keep the plane flying straight and level.
Captain Widodo could now change his course.
This is where they switch from nav to attitude.
Switching from one mode to the other forces some computerised gauges to temporarily go blank while they reset.
One is the ADI or artificial horizon, which tells the crew if the plane is flying level.
ADI goes off and stays off.
There was also another much more serious consequence to the switch.
That's where the plane starts its right roll.
The autopilot disengaged when they consciously selected from the nav mode to the attitude mode, and then the aircraft commenced an almost imperceptible roll to the right of around about one degree per second.
The captain missed a crucial step when he switched his flight computer from one mode to the other.
Quick reference handbook, please.
He should have flown his plane straight and level while the computer adjusted to the new setting.
(READS) "Maintain straight and level constant airspeed flight "until attitude displays recover, approximately 30 seconds.
" It's in the manual.
It's an oversight with grave consequences.
Without that step, the autopilot disengages completely.
(ALARM BEEPS) The flight computer did send out a warning when that happened, but the warning was ignored.
The crew didn't seem to notice that the autopilot was no longer flying the plane.
And it only took seconds for that to become a very serious problem.
The data tells investigators that this plane had a natural tendency to roll to the right.
Old planes, like old cars, don't always go straight.
Throughout the flight, the autopilot compensated for that by raising the aileron on the plane's left wing.
An aileron is a movable flap on the wing that controls how much the plane rolls to the left and right.
But once the autopilot disengaged, it stopped compensating, and the ailerons went back to a neutral position.
That allowed the plane to revert to its tendency to roll to the right.
And they don't even notice.
At this point, the plane was rolling at a rate of one degree per second.
Focused on their faulty navigation system and with thick clouds obscuring the horizon, the pilots had no idea that their plane was dipping.
It's not uncommon for pilots to get disoriented in this way.
SOEJATMAN: Your body will start to fool you.
Your senses will start sending you false information or false senses.
You might think that you are actually going straight and level, where you're actually rolling slowly to the right or to the left.
The 737 is programmed to issue a warning when it rolls past 35 degrees.
COMPUTERISED VOICE: Bank angle, bank angle, bank angle.
They get an aural warning from the airplane that says, "Hey, bank angle, bank angle.
" And at that point, they made some small inputs to the controls, but they didn't fly the airplane.
Believing that the autopilot would keep the plane level, Widodo soon turned his attention back to the problematic IRS.
Usually you would say one pilot deals with the system issue, the other pilot flies the airplane.
They were both dealing with this system issue and totally focused on the issue, so they never saw what was happening.
Just because there is an Inertial Reference System failure or, let's say in another accident, there might be an engine failure, does not mean that an aircraft has to crash.
It's 60 degrees now and there is no attempt at a recovery.
WIDODO: Don't turn it.
This is our heading! - Pull up.
Pull up! - COMPUTERISED VOICE: Pull up.
(SCREAMING) Investigators can see that when Captain Widodo DOES take action, he makes the situation much worse.
With his plane still banked drastically to the right, Captain Widodo should have levelled his wings and then pulled his nose up.
- He did the opposite.
- (SHOUTS INDISTINCTLY) He began pulling back on his control column before his wings were level.
That forced the plane into a tight spiral dive.
Basically it rolled and it just kept rolling until it almost went inverted and just kinda fell out of the sky once it got to a point where it wasn't flying like a normal airplane should.
The aircraft was descending at nearly 900km/h .
.
at a vertical speed at times reaching in excess of 21,000ft per minute.
That's almost the speed of sound and more than 150km/h faster than this plane was designed to withstand.
- COMPUTERISED VOICE: Pull up.
- It's rolling over, rapid descent.
COMPUTERISED VOICE: Pull up, pull up.
They can't recover now.
At that speed, the plane is no longer able to hold itself together.
- (CRASH!) - And that sound .
.
that's the sound of the plane coming apart.
The black boxes have revealed how Flight 574 crashed.
But they also raise crucial questions.
It's just one error after another.
There was ample opportunity, ample time for the pilots to correct the situation.
The investigators have come to a disturbing conclusion.
The only mechanical failure was with the plane's navigation system .
.
and that shouldn't have caused the crash.
The more significant failures were human.
Put the IRS in attitude.
COMPUTERISED VOICE: Bank angle.
But why should qualified pilots make these disastrous mistakes? Don't turn it! This is our heading! To find these answers, investigators must look at the airline itself.
This one accident will raise serious questions about Indonesia's entire aviation industry.
Investigators turn their attention from the actions of the pilots on Flight 574 to the airline that employed them - Adam Air.
Adam Air was founded in 2002 by a wealthy businesswoman named Sandra Ang.
Ang named the airline after her son, Adam, whom she also appointed as the company's president.
We need to know more about your training program.
The investigators interview Adam Air pilots.
Did the airline provide any training on recovery procedures in the event of an IRS failure? No.
The want to find out more about how the airline trained its flight crews.
What about recovery techniques? IRS troubleshooting? No? What they uncover is disturbing.
Thank you, gentlemen, for your time.
As they dig deeper, investigators find an airline plagued with safety issues.
11 months before the Adam Air crash, in February 2006, another Adam Air plane, Flight 782, flew off course the same way as Flight 574.
That crew was also getting faulty navigation data, but they couldn't even reach controllers on the radio.
They couldn't get directions.
They were badly lost for three hours.
Like Flight 574, they had a malfunctioning IRS.
In the end, the plane landed almost 500km south of where it should have been.
SOEJATMAN: They just continued until they found an island, and it had an airport in it and they said, "OK, we have to land there, "otherwise we don't know where we're gonna go.
" They landed and they didn't know exactly where they were until they landed.
Six months after Flight 574, the European Commission banned all Indonesian airlines from flying to Europe.
That sent a very strong message to the whole world that we, the European Union, believe that all Indonesian airlines are unsafe and you should not fly on them.
Then, in March 2008, there's another accident involving Adam Air, this time in the city of Batam.
And the airplane slewed off the runway, came to rest on the side.
The evacuation was a bit strange.
No slides were deployed and that was the final accident.
And after that, I think everybody said, "Enough's enough.
" You know? Immediately after the crash in Batam, the Indonesian Government suspended and then ultimately revoked Adam Air's licence to operate.
It is also apparent that Adam Air isn't the only Indonesian airline with problems.
Prior to the Adam Air crash, Indonesia experienced a bad crash about every year to 18 months.
Many of those accidents involved the discount carriers that the Government had allowed to thrive.
More than 50 such airlines were in operation at the time of the Adam Air crash.
The problem, though, was that this expansion occurred in a way that was not properly monitored, not properly regulated by the Government.
Thousands and thousands of people are being employed to work for airlines when they just don't have the experience to do so and are not being adequately trained, as the investigation reports into the Adam Air crash demonstrated.
Indonesia's poor safety record forces the Government to take steps to improve airline safety throughout the country.
It begins rating airlines on safety and grounds those that don't comply.
There have been fewer fatal incidents since the reforms.
But a year and half after it was put in place, the European Union's ban on Indonesian airlines was still in effect.
Those familiar with Indonesian aviation think the reforms could go even further.
So that we have no more Adam Airs, we have no more companies that cut costs too much .
.
and gives all this extra risk to the public, because that's not what the public should receive.
The public should receive a reliable and safe means of air transportation.
Supertext Captions by Red Bee Media Australia
He's flying north.
NARRATOR: A Boeing 737 is badly off course.
(THUNDER CRASHES) Adam 574, confirm our position, please.
The crew struggles to get the plane back on track.
This is crazy! They're lost in a violent storm.
When their plane starts rolling over - Pull up! - COMPUTERISED VOICE: Pull up.
Pull up! (SCREAMING) The lives of 102 people are at risk.
Adam 574, Yu Jung, Control.
Then, mysteriously, Adam Air Flight 574 disappears without a trace.
January 1, 2007.
Surabaya, Indonesia.
It's New Year's Day.
There are celebrations throughout the country.
Surabaya's airport is bustling .
.
and not just because of the holidays.
Indonesia is experiencing a boom of budget airlines.
One of those new airlines is Adam Air.
Good afternoon, Departure.
This is Adam 574.
Adam, 574.
This is Ground Control.
Go ahead.
Adam Air was successful because it provided a fresh image to the industry.
They came in with bright colours.
Their airplanes were painted a fantastic orange.
The crew was, you know, flashy uniform.
They had everything right going for them.
Captain Refri Widodo has been flying with Adam Air for six months.
Today he's in command of Flight 574, a short domestic flight.
His copilot, Yoga Susanto, has been with the airline for almost a year and a half.
(BABY CRIES) There are 96 passengers and six crew members on today's flight.
Controllers at the airport are busy juggling planes.
(SPEAKS INDISTINCTLY) Adam 574 is clear for take-off.
- 80 knots.
- Check.
Rotate.
Today's flight is a routine two-hour hop.
From Surabaya on the island of Java to Manado on the island of Sulawesi, almost 1,700 kilometres north-east.
It's the beginning of the rainy season.
Weather is unpredictable.
Forecasters are expecting fierce storms.
Captain Widodo is aware that there may be bad weather ahead.
COMPUTERISED VOICE: Turn right, direct to FANDO, and climb to flight level 330.
Roger.
Turn right.
Direct to FANDO and climb to flight level 330.
Adam 574.
Minutes after take-off, the crew turns on the autopilot.
The flight computer will fly the plane and navigate it along a preplanned route Manado.
(BABY CRIES) Now passing flight level 220, climbing to flight level 330.
Roger, Adam 574.
Track direct to DIOLA.
Confirmed.
Tracking direct to DIOLA.
Adam 574.
Less than half an hour into the flight, air traffic controllers notice something out of the ordinary.
Where's Adam direct to? My God.
He's flying north.
Flight 574 has flown off course and is now heading into a violent storm.
Air traffic controllers don't know why.
Yes.
Mm-hm.
On board the plane, the pilots try to understand how far they have drifted off course The IRS.
28 is the difference.
.
.
and try to fix the problem with a computerised system that handles navigation.
May I have your attention? This is your captain speaking.
We are about to experience some turbulence.
(CRIES) Could all the passengers return to their seats? Controllers on the ground try to get Flight 574 back on course, giving them directions to their next assigned waypoint called DIOLA.
Adam Air 574, maintain 350.
Direct to DIOLA.
Confirmed, flight level 350.
Direct to DIOLA, Adam 574.
But to get there, Flight 574 must pass through a severe storm.
137km/h winds beat on the plane's hull.
It's pounded by hail and rain.
The crew is not just concerned with the weather.
They're still also trying to understand the problem with the plane's navigation system.
This is messed up.
Getting lost over the ocean is everyone's worry because when you lose your navigational instruments or you lose trust of your navigational instruments, what do you do? Copilot Susanto consults the aircraft's handbook.
It's starting to fly like a bamboo ship.
Captain Widodo doesn't know where he is.
- He needs directions.
- Confirm our position.
Adam 574.
Confirm our position, please.
Roger, Adam 574.
Position is 125 miles.
Mike Kilo Sierra.
Crossing radio 307.
Mike Kilo Sierra.
The weather in Mike Kilo Sierra isn't good.
The storm is growing worse.
This is crazy! We're going to get lost if it stays like this.
Captain Widodo wants to take over navigation of the plane from the flight computer.
OK.
Put the IRS in altitude.
But suddenly a warning.
(ELECTRONIC BEEPING) The autopilot has disengaged completely.
Then many of Susanto's computerised instruments go blank.
The crew doesn't notice that their plane is rolling over.
Flight 574 is banking at a dangerous angle.
Enough of this! COMPUTERISED VOICE: Bank angle.
Bank angle.
Bank angle.
If it rolls too far over, it could send the plane and the 102 people on board into a fatal downward spiral.
(SCREAMING) OK.
Put it back on navigate.
Put it back on navigate! Yes.
Put it on navigate! Captain Widodo wants to re-engage the flight computer's navigation system.
(SCREAMING) The plane is still rolling, and now its nose has started to point downward.
(SCREAMING) COMPUTERISED VOICE: Sink rate.
Another alarm tells the pilots that they are entering a steep descent.
Pull up.
Don't turn it! This is a headache.
- Pull up! - Pull up.
- Pull up! (SHOUTS) - Pull up.
Adam 574, Yu Jung, Control.
Adam 574, Yu Jung, Control.
Adam 574, radar service terminated.
Please contact Yu Jung, Control at 128.
1.
Inexplicably, Flight 574 has disappeared.
News of Adam Air Flight 574's disappearance spreads quickly.
The Indonesian Government starts mobilising search and rescue teams to find it.
Indonesia's National Transportation Safety Committee, or NTSC, is also notified.
The NTSC is responsible for finding out what went wrong in any plane crash.
Frans Wenas is in charge of investigating Adam Air 574.
The first steps that we take when there was an accident or serious incident We will find all the resources that we have and get the team together before we despatch to the area.
Working with air traffic control, the searchers try to pinpoint the last recorded location of Flight 574 .
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about halfway through its intended journey.
OK.
So, right around here.
But the plane could have flown hundreds of kilometres after that signal was received.
It's impossible to pinpoint the exact location.
Without a specific location, searchers try to figure out how large an area to scan.
Since they know how much fuel was on board, investigators can calculate how far the plane could have flown since it was last detected.
If this is their last radar hit, they didn't have enough fuel to fly any further than this.
More than 3,000 people are sent out to look for the plane.
The Indonesians are joined by a US Navy vessel.
But the area they have to search is the size of Ireland.
The teams don't even know whether to look on land or on water.
And as long as there was no definitive word, hope remained.
12 hours pass without any confirmed sightings.
And then friends' and relatives' hopes are raised with news that survivors have been found.
Rescue teams hurry to the island of Sulawesi, hoping to return survivors to their families.
But when the first officials get there, they find that these survivors are not from the flight at all.
So they were ferry survivors, not airplane survivors.
They're from a ship that sank in another storm near where Flight 574 is thought to have crashed.
Now the rescue teams are back to square one.
It let people's hopes up.
And people flocked to Makassar, and they were finding ways how to get to the crash site only to find that it's not there.
For family members, it's a bitter disappointment.
(SPEAKS INDONESIAN LANGUAGE) TRANSLATOR: We were ashamed because the information was already spread all over before we verified it.
Our government was embarrassed that we publicised that information.
It's been a week since the crash.
(SPEAKS INDISTINCTLY) With each passing day, the chance of finding any survivors grows smaller.
There was still no clear picture of exactly where the plane had crashed and how it had gone down and why it had gone down.
Wenas needs to locate the wreckage as soon as possible.
Most of all, he needs the two black boxes that record conversations in the cockpit and flight data.
There are beacons attached to the boxes, but they only have a 30-day battery life.
Nine days after the crash of Adam Air Flight 574, a fisherman finds what he thinks might be part of an airplane 300 metres off the coast of Sulawesi.
The piece is taken to an Indonesian air force base for analysis.
Frans Wenas quickly identifies that it is part of a right elevator.
He examines it to see if it belongs to Adam Air Flight 574.
We checked with the serial numbers, we checked with the part numbers.
The numbers match.
So we are definitely sure that it is from the aircraft.
The finding confirms that Flight 574 crashed at sea.
The team can now narrow down its search to the area where the elevator was found.
Since the accident involves an American-made plane, the US National Transportation Safety Board joins the investigation .
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and they send structural engineer Clint Crookshanks to Indonesia.
We started working with the NTSC to look at radar data, air traffic transmissions, weather data - trying to bring all that information together to find the airplane.
The water that investigators plan to search for wreckage is 6,500ft deep, much too deep to send down divers.
It was quite deep water, deeper than we're normally used to recovering airplanes from.
The Indonesian Government wants Adam Air to pay for the salvage operation.
Investigators meet with representatives of the airline.
It is going to be expensive.
We need to hire contractors to go down that far.
Adam Air felt that its responsibility only went so far.
The Government and most of public opinion believed that Adam Air's responsibility was actually almost total because they were the owners of the airline.
The airline refuses to pay for the salvage, triggering a lengthy negotiation.
This is not good news for Frans Wenas.
Unless someone puts up the money to search the seabed for wreckage, the mystery of Flight 574 will not be solved.
It is also a blow to the families of the victims.
The families obviously wanted to know what had happened to their loved ones, and they did want the Government and Adam Air to combine to get the flight data recorders out of the water.
As the investigation stalls, public anger grows.
People were becoming more and more critical of Adam Air and the way it was being run But then, after seven months of negotiating This is good news.
Thank you.
.
.
Adam Air agrees to help pay for the salvage.
Phoenix International, an American company specialising in deepwater salvage, starts the operation on August 24.
But the time they've lost has had a serious consequence.
Although they have a fix on the location of the crash, the locator beacons attached to the black boxes have gone dead.
Without the beacon, finding two small boxes among the wreckage will be a huge challenge.
To make matters worse, Adam Air has only put up enough money for one week of searching.
So it was like, "Go out there.
"If you don't find anything in seven days, you're done.
" After locating debris with sonar, an unmanned remote-controlled submarine is sent down to look for the black boxes.
Alright.
How are we doing? We dove on one location first.
We got to that GPS location.
There was nothing there.
Pull up quadrant 3.
So we sat down and decided we'd do a grid search about that point, and so we did a very methodical search.
OK.
Three degrees.
Alright.
Slow.
Slow.
We're coming up on something.
We started picking up small, lightweight pieces of airplane wreckage - things like life vests, seat trays, light bits of metal.
Oh, my God.
This is it.
Investigators get their first look at the wreckage.
This plane is ripped apart.
The state of the wreckage illustrates just how violent this plane crash was.
The little pieces of wreckage didn't tell us anything about the cause of the crash.
They did tell us, however, that the airplane hit the water at a very high rate of speed.
This was the most fragmented airplane that I have ever seen.
Only two days into the operation, Crookshanks spots something.
Alright, stop.
Rotate back five degrees.
I noticed on the left side of the video screen something that appeared to be orange, and I instructed the ROV operator to take a closer look at it.
That's it.
That'sthat's it.
OK.
Once we got over there, we realised that this, in fact, was the FDR.
We were very excited that we had seen and recovered one of the boxes.
Investigators soon find the cockpit voice recorder nearby.
Alright.
Stop! That's it.
Their week is up.
The salvage operation is over.
Investigators now hope that they have all the clues they need to solve this accident.
The black box is the only source for the evidence that we have because we don't have the wreckage, we don't have the witnesses.
But the boxes have been lying on the bottom of the sea for almost eight months.
They could be damaged beyond repair.
They may not yield any information at all.
The black boxes from Adam Air Flight 574 are taken to the National Transportation Safety Board in Washington, DC.
Investigators think the labs there are the best bet at salvaging any possible information.
CROOKSHANKS: If an FDR is found in salt water, it needs to be washed in fresh water and then contained in water the entire time until it makes it to our lab.
Salt and air together create a chemical reaction that results in rust.
The rust can damage the electronic components in the recorders.
Keeping them submerged in fresh water delays that reaction.
Frans Wenas also makes the trip to the United States.
We thought there might be an issue in recovering the data.
It wasn't as damaged as many others we've seen, so we were fairly confident if there was data recorded we would be able to get the data off of it.
Technicians begin the painstaking process of retrieving the information.
The job is a multinational effort.
MAN: The Australian Transport Safety Bureau was requested to assist.
We have an excellent relationship with the NTSB folk, and so our flight recorder specialist went to the United States and worked alongside the NTSB.
The electronic components containing the data are carefully removed and dried.
Then the information is uploaded onto a computer.
As the delicate procedure of recovering the data from both recorders progresses .
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investigators are aware that they have an additional concern.
CROOKSHANKS: One problem that we ran up against in this investigation is the maintenance records indicated that the flight data recorder was written up as being inoperable in the weeks prior to the crash.
We were concerned with that, in that if we found the FDR, it may not have recorded anything.
Investigators keep their fingers crossed.
We've got it all.
It's all there.
I was confident once we found out that we had 100% of the data that we would be able to solve this accident.
The two black boxes provide investigators with the first solid clues about why Flight 574 fell from the sky.
SUSANTO: (ON RECORDING) Good afternoon, Departure.
This is Adam 574.
Now passing flight level 220.
Climbing to flight level 330.
Roger, Adam 574.
Track direct to DIOLA.
Confirmed.
Tracking direct to DIOLA.
Adam 574.
The conversation in the cockpit tells investigators that the crew knew that the plane's navigation system was sending them off course The IRS.
28 is the difference.
They're drifting.
.
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and that they were preoccupied with fixing that problem.
This is messed up.
Where's Adam direct to? My God.
He's flying north.
Adam Air 574, maintain 350 direct to DIOLA.
Confirm flight level 350 direct to DIOLA, Adam 574.
To get from one waypoint to the next, the flight computer always has to know the plane's exact location.
That information comes from a component called the IRS or Inertial Reference System.
It tracks every adjustment to the plane's course to calculate its exact position.
It then feeds that information to the autopilot.
The autopilot needs to know where the aircraft is and where it needs to go.
The autopilot takes those data from the IRS in terms of height, heading and speed.
But for the system to keep track of the plane's heading, it has to know where the plane started.
The IRS has to be calibrated before take-off.
Usually the crew will enter the coordinates of the gate as the starting point for the computer to track.
Investigators wonder if the IRS guided the plane off course because the wrong initial coordinates were entered.
We just got this.
They check this by looking at information from the flight data recorder.
The numbers are fine when they're on the ground.
Yes, yes.
The data confirms the IRS was calibrated before Adam Air Flight 547 took off.
- This is where it begins.
- That's right.
But for some reason, the IRS began to send the plane off course almost as soon as the flight got in the air.
It just gets worse and worse.
I have something else I'd like to show you.
Some maintenance logs.
Crookshanks and Wenas look at the maintenance history of the IRS system that was on board Flight 574.
As you can tell, there's more than 100 write-ups here.
Look at this.
Same unit.
- Same problem.
- That's right.
The history shows that there had been numerous complaints about the plane's navigation system over the past three months.
Again and again.
Investigators wonder why the airline didn't fix the problem.
In the case of the IRS of this aircraft, that unit should have been taken out and sent to Maintenance for calibration or repairs.
Investigators discover that when pilots complained about a faulty IRS unit, the airline didn't fix it properly.
They would either swap it with a unit from another plane .
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or often they would only do a basic cleaning of the malfunctioning unit.
MAN: They'd just pull up the connectors, spray it with some lubricant cleaners then put it back on, did some ground test and then just put "ground test OK" on the maintenance log.
Since the IRS is such a vital piece of equipment, this is contrary to all recommended repair policies.
Investigators listen to the cockpit voice recorder, hoping to discover how the malfunctioning IRS contributed to the crash.
This is crazy! We're going to get lost if it stays like this.
Don't turn it.
This is our heading! - Pull up, pull up! - COMPUTERISED VOICE: Pull up.
If you have a failure in one system, it shouldn't cause an accident.
Nothing they hear leads them to believe that an IRS malfunction alone could have caused the plane to crash.
Investigators now wonder if the severe storm Flight 574 flew into somehow played a role in this crash.
This is messed up.
This is really messed up.
It's starting to fly like a bamboo ship.
Let's confirm our position.
In order to determine if weather was a factor in the Adam Air crash, investigators need a more complete picture of what happened on board the flight.
They want to know everything the crew did and said from the time they discovered that they were off course to the time they hit the water.
To do this, they combine the data from the two black boxes to create a computer simulation of the flight.
Investigators return to Jakarta to study the simulation.
The weather in Mike Kilo Sierra isn't good.
This is crazy! We're going to get lost if it stays like this.
The can see that throughout most of the flight, the computer was navigating the plane.
But since the flight computer was sending the plane off course Position, please.
.
.
the captain decided to navigate the plane himself.
OK, put the IRS in altitude.
Copilot Susanto switched the navigation system to a mode that would keep the plane flying straight and level.
Captain Widodo could now change his course.
This is where they switch from nav to attitude.
Switching from one mode to the other forces some computerised gauges to temporarily go blank while they reset.
One is the ADI or artificial horizon, which tells the crew if the plane is flying level.
ADI goes off and stays off.
There was also another much more serious consequence to the switch.
That's where the plane starts its right roll.
The autopilot disengaged when they consciously selected from the nav mode to the attitude mode, and then the aircraft commenced an almost imperceptible roll to the right of around about one degree per second.
The captain missed a crucial step when he switched his flight computer from one mode to the other.
Quick reference handbook, please.
He should have flown his plane straight and level while the computer adjusted to the new setting.
(READS) "Maintain straight and level constant airspeed flight "until attitude displays recover, approximately 30 seconds.
" It's in the manual.
It's an oversight with grave consequences.
Without that step, the autopilot disengages completely.
(ALARM BEEPS) The flight computer did send out a warning when that happened, but the warning was ignored.
The crew didn't seem to notice that the autopilot was no longer flying the plane.
And it only took seconds for that to become a very serious problem.
The data tells investigators that this plane had a natural tendency to roll to the right.
Old planes, like old cars, don't always go straight.
Throughout the flight, the autopilot compensated for that by raising the aileron on the plane's left wing.
An aileron is a movable flap on the wing that controls how much the plane rolls to the left and right.
But once the autopilot disengaged, it stopped compensating, and the ailerons went back to a neutral position.
That allowed the plane to revert to its tendency to roll to the right.
And they don't even notice.
At this point, the plane was rolling at a rate of one degree per second.
Focused on their faulty navigation system and with thick clouds obscuring the horizon, the pilots had no idea that their plane was dipping.
It's not uncommon for pilots to get disoriented in this way.
SOEJATMAN: Your body will start to fool you.
Your senses will start sending you false information or false senses.
You might think that you are actually going straight and level, where you're actually rolling slowly to the right or to the left.
The 737 is programmed to issue a warning when it rolls past 35 degrees.
COMPUTERISED VOICE: Bank angle, bank angle, bank angle.
They get an aural warning from the airplane that says, "Hey, bank angle, bank angle.
" And at that point, they made some small inputs to the controls, but they didn't fly the airplane.
Believing that the autopilot would keep the plane level, Widodo soon turned his attention back to the problematic IRS.
Usually you would say one pilot deals with the system issue, the other pilot flies the airplane.
They were both dealing with this system issue and totally focused on the issue, so they never saw what was happening.
Just because there is an Inertial Reference System failure or, let's say in another accident, there might be an engine failure, does not mean that an aircraft has to crash.
It's 60 degrees now and there is no attempt at a recovery.
WIDODO: Don't turn it.
This is our heading! - Pull up.
Pull up! - COMPUTERISED VOICE: Pull up.
(SCREAMING) Investigators can see that when Captain Widodo DOES take action, he makes the situation much worse.
With his plane still banked drastically to the right, Captain Widodo should have levelled his wings and then pulled his nose up.
- He did the opposite.
- (SHOUTS INDISTINCTLY) He began pulling back on his control column before his wings were level.
That forced the plane into a tight spiral dive.
Basically it rolled and it just kept rolling until it almost went inverted and just kinda fell out of the sky once it got to a point where it wasn't flying like a normal airplane should.
The aircraft was descending at nearly 900km/h .
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at a vertical speed at times reaching in excess of 21,000ft per minute.
That's almost the speed of sound and more than 150km/h faster than this plane was designed to withstand.
- COMPUTERISED VOICE: Pull up.
- It's rolling over, rapid descent.
COMPUTERISED VOICE: Pull up, pull up.
They can't recover now.
At that speed, the plane is no longer able to hold itself together.
- (CRASH!) - And that sound .
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that's the sound of the plane coming apart.
The black boxes have revealed how Flight 574 crashed.
But they also raise crucial questions.
It's just one error after another.
There was ample opportunity, ample time for the pilots to correct the situation.
The investigators have come to a disturbing conclusion.
The only mechanical failure was with the plane's navigation system .
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and that shouldn't have caused the crash.
The more significant failures were human.
Put the IRS in attitude.
COMPUTERISED VOICE: Bank angle.
But why should qualified pilots make these disastrous mistakes? Don't turn it! This is our heading! To find these answers, investigators must look at the airline itself.
This one accident will raise serious questions about Indonesia's entire aviation industry.
Investigators turn their attention from the actions of the pilots on Flight 574 to the airline that employed them - Adam Air.
Adam Air was founded in 2002 by a wealthy businesswoman named Sandra Ang.
Ang named the airline after her son, Adam, whom she also appointed as the company's president.
We need to know more about your training program.
The investigators interview Adam Air pilots.
Did the airline provide any training on recovery procedures in the event of an IRS failure? No.
The want to find out more about how the airline trained its flight crews.
What about recovery techniques? IRS troubleshooting? No? What they uncover is disturbing.
Thank you, gentlemen, for your time.
As they dig deeper, investigators find an airline plagued with safety issues.
11 months before the Adam Air crash, in February 2006, another Adam Air plane, Flight 782, flew off course the same way as Flight 574.
That crew was also getting faulty navigation data, but they couldn't even reach controllers on the radio.
They couldn't get directions.
They were badly lost for three hours.
Like Flight 574, they had a malfunctioning IRS.
In the end, the plane landed almost 500km south of where it should have been.
SOEJATMAN: They just continued until they found an island, and it had an airport in it and they said, "OK, we have to land there, "otherwise we don't know where we're gonna go.
" They landed and they didn't know exactly where they were until they landed.
Six months after Flight 574, the European Commission banned all Indonesian airlines from flying to Europe.
That sent a very strong message to the whole world that we, the European Union, believe that all Indonesian airlines are unsafe and you should not fly on them.
Then, in March 2008, there's another accident involving Adam Air, this time in the city of Batam.
And the airplane slewed off the runway, came to rest on the side.
The evacuation was a bit strange.
No slides were deployed and that was the final accident.
And after that, I think everybody said, "Enough's enough.
" You know? Immediately after the crash in Batam, the Indonesian Government suspended and then ultimately revoked Adam Air's licence to operate.
It is also apparent that Adam Air isn't the only Indonesian airline with problems.
Prior to the Adam Air crash, Indonesia experienced a bad crash about every year to 18 months.
Many of those accidents involved the discount carriers that the Government had allowed to thrive.
More than 50 such airlines were in operation at the time of the Adam Air crash.
The problem, though, was that this expansion occurred in a way that was not properly monitored, not properly regulated by the Government.
Thousands and thousands of people are being employed to work for airlines when they just don't have the experience to do so and are not being adequately trained, as the investigation reports into the Adam Air crash demonstrated.
Indonesia's poor safety record forces the Government to take steps to improve airline safety throughout the country.
It begins rating airlines on safety and grounds those that don't comply.
There have been fewer fatal incidents since the reforms.
But a year and half after it was put in place, the European Union's ban on Indonesian airlines was still in effect.
Those familiar with Indonesian aviation think the reforms could go even further.
So that we have no more Adam Airs, we have no more companies that cut costs too much .
.
and gives all this extra risk to the public, because that's not what the public should receive.
The public should receive a reliable and safe means of air transportation.
Supertext Captions by Red Bee Media Australia