Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B737-300 19 DECEMBER 1997

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National Transportation Safety Committee Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B737-300 9V-TRF MUSI RIVER, PALEMBANG, INDONESIA 19 DECEMBER 1997 Jakarta, 14 December 2000 Department of Communications Republic of Indonesia Investigation of Aircraft Accident SilkAir Flight MI 185 Boeing B737-300, 9V-TRF Musi River, Palembang, Indonesia 19 December 1997 FINAL REPORT Note: • All times indicated in this report are based on FDR UTC time. Local time is UTC + 7 hours. i Abstract This report is on the accident involving the SilkAir flight MI 185, a Boeing B737-300, which crashed into the Musi river near Palembang, South Sumatra, Indonesia, on 19 December 1997, at about 16:13 local time (09:13 UTC). SilkAir flight MI 185 was operating as a scheduled passenger flight from Jakarta Soekarno-Hatta International Airport to Singapore Changi Airport. The flight departed about 15:37 local time with 97 passengers, five cabin crew and two cockpit crew. The airplane descended from its cruising altitude of 35,000 feet and impacted the Musi river, near the village of Sunsang, about 30 nautical miles north-north-east of Palembang in South Sumatra. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. Prior to the sudden descent from 35,000 feet, the flight data recorders stopped recording at different times. There were no mayday calls transmitted from the airplane prior or during the descent. All 104 persons on board did not survive the accident, and the airplane was completely destroyed by impact forces. Except parts of the empennage that found on land, most of the wreckage was found buried in the bottom of the Musi river. About 73 percent by weight of wreckage was recovered, although due to the magnitude of destruction of the airplane, the small mangled pieces precluded finding clues, evidence or proof as to what have happened, how and why. The safety issues in this report focused on the areas of flight operations, the flight data recorders, the human factors and control systems malfunctions. The investigation yielded very limited data and information to make conclusions possible. The report is pursuant to the technical investigation conducted by the National Transportation Safety Committee (NTSC) of Indonesia. The investigation was conducted in accordance with the standards and recommended practices of Annex 13 to the Convention on International Civil Aviation. In accordance with Annex 13, the sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability. ii This page is left intentionally blank. iii Table of Contents Errata Abstract i Abbreviations vii Glossary of Terms x 1 FACTUAL INFORMATION 1 1.1 History of Flight 1 Synopsis 1 1.2 Injuries to Persons 1 1.3 Damage to Aircraft 2 1.4 Other Damage 2 1.5 Personnel Information 2 1.5.1 Pilot-In-Command (PIC) 2 1.5.2 First Officer (F/O) 2 1.6 Aircraft Information 3 1.6.1 Aircraft Data 3 1.6.2 Aircraft History 3 1.6.3 Weight and Balance 4 1.7 Meteorological Information 4 1.7.1 General Weather Condition over South Sumatra 4 1.7.2 Weather Report over Palembang and Its Surroundings 4 1.7.3 Information on Wind Directions and Strength 4 1.7.4 Weather En-route 5 1.8 Aids to Navigation 5 1.9 Communications 5 1.10 Aerodrome Information 5 1.11 Flight Recorders 6 1.11.1 FDR 6 1.11.2 FDR Data Recovery 6 1.11.3 CVR 7 1.12 Wreckage and Impact Information 7 1.12.1 Aircraft Structures 8 1.12.1.1 Wings 9 1.12.1.2 Fuselage 9 1.12.1.3 Empennage 10 1.12.1.4 Horizontal Tailplane 10 1.12.1.5 Vertical Tailplane 12 1.12.2 Power plants 12 1.12.2.1 Engine 13 1.12.2.2 Main Engine Control (MEC) / Governor 13 1.12.2.3 Throttle Box 14 1.12.3 PCU and Actuator Tear Down and Examination 14 1.12.3.1 Tear Down Activities 14 1.12.3.2 Spoiler/Flap/Slat/Thrust Reverser Actuators 15 1.12.3.3 Actuators Found in Non-neutral Position 15 1.12.4 Other Aircraft Components 17 1.13 Medical and Pathological Information 17 1.14 Fire 17 1.15 Survival Aspects 18 iv 1.16 Tests and Research 18 1.16.1 CVR Circuit Breaker Actuation Test 18 1.16.2 Captain Seat Belt Buckle Sound Test 19 1.16.3 Voice Recognition of ATC Recording using Audio Spectral Analysis 20 1.16.4 Trajectory Studies 20 1.16.5 Flutter Studies 21 1.16.6 Flight Simulation Tests 21 1.17 Organizational and Management Information 22 1.18 Other Information 23 1.18.1 Air Traffic Control 23 1.18.2 Radar Surveillance 23 1.18.2.1 Radar Facilities. 23 1.18.2.2 Radar Data Output 24 1.18.2.3 Aircraft Flight Path Based on Radar 24 1.18.3 PIC’s Background and Training 24 1.18.3.1 Professional Background in RSAF 24 1.18.3.2 Professional Background with SilkAir. 25 1.18.3.3 Financial Background Information 25 1.18.3.4 Recent Behaviour 26 1.18.4 F/O’s Background and Training 26 1.18.4.1 Professional Background with SilkAir 26 1.18.4.2 Financial Background Information 27 1.18.4.3 Recent Behaviour 27 1.18.5 Relationship Between the PIC and the F/O 27 2 ANALYSIS 28 2.1 Introduction 28 2.2 Aircraft Structural and Systems Integrity 28 2.2.1 Horizontal Stabilizers and Elevators 29 2.2.2 Vertical Stabilizer and Rudder 29 2.3 Break Up of the Empennage 30 2.3.1 Results of Trajectory Studies 30 2.3.2 Results of Flutter Studies 30 2.3.3 Explanation to the Break Up of the Empennage 31 2.4 Power Control Units and Actuators 31 2.4.1 Main Rudder PCU 31 2.4.2 Standby Rudder PCU 32 2.4.3 Aileron PCU 32 2.4.4 Elevator PCU 32 2.4.5 Horizontal Stabilizer Jackscrew 32 2.4.6 Other Actuators 34 2.5 Powerplant 34 2.6 Stoppage of the CVR and FDR 35 2.6.1 CVR Stoppage 35 2.6.2 FDR Stoppage 36 2.7 Radio Transmission Voice Recognition 36 2.8 Maintenance Aspects 37 2.8.1 Aircraft Maintenance 37 2.8.2 Patch Repair 37 2.9 General Operational Issues 37 2.10 Simulated Descent Profile 38 2.11 High Speed Descent Issues 39 2.11.1 Mach Trim System and its Function 39 2.11.2 Emergency Descent due to Fire, Smoke or Depressurization 39 v 2.12 General Human Performance Issues 40 2.13 Human Factors Aspects of the CVR and ATC Recordings 41 2.13.1 CVR 41 2.13.2 ATC Recordings 41 2.14 Specific Human Factors Issues 42 2.14.1 Personal Relationships 42 2.14.2 First Officer (F/O) 42 2.14.3 Pilot-in-Command (PIC) 42 2.14.3.1 Recent Behaviour 43 2.14.3.2 Insurance 43 2.14.3.3 Overall Comments on Pilot-in-Command 44 3 CONCLUSIONS 45 3.1 Findings 45 Engineering and Systems 45 Flight Operations 45 Human Factors 46 3.2 Final Remarks 46 4 RECOMMENDATIONS 48 Recommendations to manufacturers 48 General recommendation 48 REFERENCES 49 FIGURES Figure 1 Route from Jakarta to Singapore over Sumatra, Indonesia 50 Figure 2 Sequence of events 52 Figure 3 Boeing B737-300 – Three view drawing 53 Figure 4 Flight Data Recorder (FDR) 54 Figure 5 Cockpit Voice Recorder (CVR) 56 Figure 6 Debris recovery 57 Figure 7 Sketch of the wreckage pieces found on land 59 Figure 8 Picture of wreckage recovered from the river 60 Figure 9 Sketch of fuselage skin patch repair 64 Figure 10 Sketch of empennage parts found on land 65 Figure 11 Picture of the reconstructed empennage 75 Figure 12 Impact marks at the cam feel centering unit 76 Figure 13 Pictures of horizontal stabilizer jackscrew 77 Figure 14 Diagram of debris distribution analysis 80 Figure 15 Boeing B737-300 flutter flight envelope diagram 83 Figure 16 Corrected radar data 84 Figure 17 Wiring diagram 24-58-11 85 Figure 18 Flight control surfaces location 86 APPENDICES Appendix A Transcript of the Last Portion of CVR Recording A-1 Appendix B Plots of the Last Portion of Several FDR Parameters B-1 Appendix C Transcript of ATC recording C-1 Appendix D Wreckage weight D-1 Appendix E Actuator matrix E-1 Appendix F Letters from AlliedSignal F-1 vi Appendix G Results of flight simulation exercises G-1 Appendix H Site Acceptance Certificate of the Hughes GUARDIAN System H-1 Appendix I Professional events in the Flight Crew’s career during 1997 I-1 Appendix J History of FAA AD related to Boeing 737 rudder system J-1 Appendix K Boeing B737 non-normal procedures - emergency descent K-1 Appendix L Boeing B737 Alert Service Bulletin, Subject on Flight Controls – Trailing Edge Flap and Horizontal Stabilizer Trim Systems L-1 Appendix M Singapore Accredited Representative’s Comments on Draft Final Report M-1 Appendix N USA Accredited Representative’s Comments on Draft Final Report N-1 vii Abbreviation AAIB Air Accidents Investigation Branch AAIC Aircraft Accident Investigation Commission AC Advisory Circular AD Airworthiness Directive AFM Airplane Flight Manual AFS Auto-Flight System agl above ground level APU Auxiliary Power Unit ASB Alert Service Bulletin ASRS Aviation Safety Reporting System ATC Air Traffic Control ATP Airline Transport Pilot ATPL Airline Transport Pilot License ATS Air Traffic Services BASI Bureau of Aviation Safety Investigation BEA Bureau Enquétes Accidents CAAS Civil Aviation Authority of Singapore CAM Cockpit Area Microphone CB Circuit Breaker CG Center of Gravity CPL Commercial Pilot License CRM Crew Resource Management CRT Cathode Ray Tube CVR Cockpit Voice Recorder DFDAU Digital Flight Data Acquisition Unit DME Distance Measuring Equipment E&E bay Electrical and Electronic compartment EDP Engine Driven Hydraulic Pump Elex Electronics EQA Equipment Quality Analysis F Fahrenheit FAA Federal Aviation Administration FAR Federal Aviation Regulations FD Flight Director FDR Flight Data Recorder FIR Flight Information Region FL Flight Level FTIR Fourier Transfer Infrared F/O First Officer GE General Electric GPS Global Positioning System viii GPWS Ground Proximity Warning System Hg Mercury HPa Hecto Pascal HQ Head Quarters Hz Hertz ICT Industrial Computed Tomography IFR Instrument Flight Rules ILS Instrument Landing Systems IP Instructor Pilot IRS Inertial Reference System JKT Jakarta KCAS Knots Calibrated Airspeed KEAS Knots Equivalent Airspeed Kg Kilogram KIAS Knots Indicated Airspeed kV Kilo Volt L Left LIP Line Instructor Pilot LOFT Line Oriented Flight Training MAC Mean Aerodynamic Chord MCIT Ministry of Communication and Information Technology M-CAB Multipurpose Cab (simulator) MEC Main Engine Control MHz Mega Hertz MM Maintenance Manual MSL Mean sea level N1 Engine Fan Speed N2 Engine Compressor Speed NG Next generation nm Nautical mile NNW north-north-west NTSB National Transportation Safety Board NTSC National Transportation Safety Committee PA Public address PATS Play-back and Test System PCU Power Control Unit PF Pilot flying PIC Pilot in Command PLB Palembang P/N Part number PNF Pilot non flying Psi Pounds per square inch ix PWC PricewaterhouseCoopers QAR Quick access recorder R Right RA Radio altitude RAPS Replay and Presentation System RSAF Republic of Singapore Air Force SB Service bulletin SEM Scanning electron microscope SIA Singapore International Airlines SIAEC Singapore Airlines Engineering Company SIN Singapore SL Service letter S/N Serial number SRM Structure Repair Manual SSCVR Solid State Cockpit Voice Recorder SSR Secondary Surveillance Radar TCAS Traffic Collision Avoidance System TOGA Take-off / go-around T/R Thrust reverser UFDR Universal Flight Data Recorder ULB Underwater Locator Beacon USA United States of America UTC Universal Time Coordinated Vd Descent speed VFR Visual flight rules VHF Very High Frequency VOR Very high frequency Omni directional Range VSV Variable Stator Vane XRD X-ray diffraction x Glossary of Terms Actuator A device that transforms fluid pressure into mechanical fore Aileron An aerodynamic control surface that is attached to the rear, or trailing edges of each wing. When commanded, the ailerons rotate up or down in opposite directions Auto-flight system A system, consisting of the auto-pilot flight director system and the auto-throttle, that provides control commands to the airplane's ailerons, flight spoilers, pitch trim, and elevators to reduce pilot workload and provide for smoother flight. The auto- flight system does not provide control commands to the airplane's rudder system Bank The attitude of an airplane when its wings are not laterally level Blowdown limit The maximum amount of rudder travel available for an airplane at a given flight condition / configuration. Rudder blowdown occurs when the aerodynamic forces acting on the rudder become equal to the hydraulic force available to move the rudder Catastrophic failure condition A failure condition that will prevent continued safe flight and landing Command mode A position on the two autopilot flight control computers, that, when engaged, allows the autopilot to control the airplane according to the mode selected via the Mode Selector switches, which include Altitude hold, Vertical Speed, Level Change, Vertical Navigation, VOR Localizer, Lateral Navigation and Heading Select Computer simulation The NTSB computer workstation-based flight simulation software used flight controls, aerodynamic characteristics, and engine models (developed by Boeing) to derive force and moment time histories of the airplanes, which can be converted into airplane motion Control wheel steering mode A position on the two autopilot flight control computers that, when engaged, allows the autopilot to maneuver the airplane through the autofilight system in response to control pressure, similar that required for manual flight, applied by either pilot. The use of control wheel steering does not disengage the autopilot. Cross-coupled The ability of the aerodynamic motion about an airplane's control axes to constantly interact and affect each other in flight. Crossover speed The speed below which the maximum roll control (full roll authority provided by control wheel input) can no longer counter the yaw / roll effects of a rudder deflected to its blowdown limit. Directional control The function that is normally performed by the rudder by pilot input or yaw damper input (also known as yaw control) E&E bay An airplane compartment that contains electrical and electronic components. Elevator An aerodynamic control surface to the back of the horizontal stabilizer that moves the airplane's nose up and down to cause the airplane to climb or descend. Empennage The tail section of an airplane, including stabilizing and flight control surfaces Flap An extendable aerodynamic surface usually located at the trailing xi edge of an airplane wing. G A unit of measurement. One G is equivalent to the acceleration caused by the earth's gravity (32.174 feet/sec2) Galling A condition in which microscopic projections or asperities bond at the sliding interface under very high local pressure. Subsequently, the sliding forces fracture the bonds, tearing metal from one surface and transferring it to the other. Heading The direction (expressed in degrees between 001 and 360) in which the longitudinal axis of an airplane is point, in relation to north Hinge moment The tendency of a force to produce movement about a hinge. Specifically the tendency of the aerodynamic forces acting on a control surface Hydraulic fluid Liquid used to transmit and distribute forces to various airplane components that are being actuated. Hydraulic pressure limiter A device incorporated in the design of the main rudder PCU on 737 next generation (NG) series airplanes to reduce the amount of rudder deflection when active. It is commanded to limit hydraulic system A pressure (using a bypass valve) as the airspeed is increased to greater than 137 knots, and it is reset as the airspeed is decreased to less than 139 knots. Hydraulic pressure reducer A modification on 737-100 through -500 series airplanes to reduce the amount of rudder authority available during those phases of flight when large rudder deflections are not required. The pressure reducer, added to hydraulic system A near the rudder PCU, will lower the hydraulic pressure from 3,000 to 1,000 pounds psi on 737-300, -400, and -500 series airplanes or to 1,400 psi on 737- 100, and -200 series airplanes. Hydraulic system A For 737-300, -400, and -500 series airplanes: A system that includes an engine-drive hydraulic pump and an electrically powered pump that provides power for the ailerons, rudder, elevators, landing gear, normal nosewheel steering, alternate brakes, inboard flight spoilers, left engine thrust reverser, ground spoilers, the system A autopilot, and the autoslats through the power transfer unit Hydraulic system B For 737-300, -400, and -500 series airplanes: A system that includes an engine-drive hydraulic pump and an electrically powered pump that provides power for the ailerons, rudder, elevators, trailing edge flaps, leading edge flaps and slats, autoslats, normal brakes, outboard flight spoilers, right thrust reverse, yaw damper, the system B autopilot, autobrakes, landing gear transfer unit, and alternate nose-wheel steering (if installed). Input shaft of the 737 main rudder PCU When rudder motion is commanded, this device moves the primary and secondary dual-concentric servo valve slides by way of the primary and secondary internal summing levers to connect hydraulic pressure and return circuits from hydraulic systems A and B so that hydraulic pressure is ported to the appropriate slides of the dual tandem actuator piston to extend or retract the main rudder PCU piston rod Interpolation The determination, or approximation of unknown values based on known values xii Kinematics A process involving fitting curves through available FDR data (such as heading, pitch and roll), obtaining flight control time history rates from these curves, and obtaining accelerations from these accelerations using Newton's laws. Knot A velocity of one nautical mile per hour. M-CAB A Boeing multi-cabin flight simulator that can be modified to simulate a variety of aircraft models and scenarios. It is an engineering simulator that is capable of simulating events that are outside of normal flight regimes, but it is not used for flight training. NG Boeing's next generation 737 series, designated as the 737-600, - 700, -800, and -900 models Overtravel The ability of a device to move beyond its normal operating position or range. Pitch control The function that is performed by the elevator by moving the control column forward or aft, which raises or lowers the nose of the airplane Power control unit (PCU) A hydraulically powered device that moves a control surface, such as a rudder, elevator, and aileron Roll Rotation of an airplane about its longitudinal axis Roll control The function that is performed by the ailerons and flight spoilers by moving the control wheel to the right or the left. Rudder An aerodynamic vertical control surface that is used to make the airplane yaw, or rotate, about its vertical axis Reverse rudder response A rudder surface movement that is opposite to the one commanded Rudder hardover The sustained deflection of a rudder at its full (blowdown) travel position Rudder trim A system that allows pilots to command a steady rudder input without maintaining foot pressure on the rudder pedals. It can be used to compensate for the large yawing moments generated by asymmetric thrust in an engine-out situation Sideload The effect of lateral acceleration, typical the result of sideslip or yaw acceleration Sideslip The lateral angle between the longitudinal axis of the airplane and the direction of motion (flight path or relative wind). It is normally produced by rudder forces, yawing motion resulting from asymmetrical thrust, or lateral gusts Slat An aerodynamic surface located on an airplane wing's leading edge that may be extended to provide additional lift Spoiler A device located on an airplane wing's upper surface that may be activated to provide increased drag and decreased lift Yaw Rotation of an airplane about its vertical axis Yaw control The function that is normally performed by the rudder by pilot input or yaw damper input, also known as directional control Yaw damper (in the 737 main rudder PCU)

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coindong 发表于 2011-9-29 18:17:16

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kmlihe 发表于 2015-7-4 14:06:51

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Aircraft Accident Report SILKAIR FLIGHT MI 185 BOEING B737-300 19 DECEMBER 1997